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PLATE I. 




Radiograph of Bronchial Tree (child). Bronchi filled with Shot No. 10. 

Diameter, .038 in. 



PHYSICAL DIAGNOSIS 

DISEASES OF THE THORACIC AND 
ABDOMINAL ORGANS. 

A Manual for Students and Physicians. 



BY 

EGBERT LEFEYEE, M.D. 

PROFESSOR OF CLINICAL MEDICINE AND ASSOCIATE PROFESSOR OF THERA- 
PEUTICS IN THE UNIVERSITY AND BELLEYUE HOSPITAL MEDICAL COLLEGE ; 
ATTENDING PHYSICIAN TO BELLEVUE AND ST. LUKE'S HOSPITALS; 
CONSULTING PHYSICIAN TO BETH-ISRAEL HOSPITAL; MEMBER OF 
THE NEW YORK ACADEMY OF MEDICINE, ETC. 



Illustrated with 74 Engravings and 12 Monochrome 

Plates 




LEA BROTHERS & CO. 

PHILADELPHIA AND NEW YORK 

1902 



THF LIBRARY OF 

CONGRESS, 
T>vo Cowtt Rec«ivpo 

190? 

COPY B 






Entered according to the Act of Congress in the year 1902, by 

LEA BROTHERS & CO. 
[n the Office of the Librarian of Congress. All rights reserved. 



TO MY FORMER STUDENTS, 

WHOSE INSISTENT 

"WHY?" 

FURNISHED THE INCENTIVE 

FOR THIS WORK. 



PREFACE 



The great number of works on Physical Diagnosis 
deterred me for a long time from writing another, and 
it was only at the urgent request of a number of my 
former students that 1 undertook to put in permanent 
form the methods that I have used for a number of years 
in teaching. 

Especial emphasis has been laid on the altered 
anatomy of the organs under examination, and its rela- 
tion to the physical signs. The resjnratory and cardiac 
sounds, their production and their modifications, both 
normal and pathological, have been discussed more fully 
than in most books of like scope, as experience has shown 
that unless the student clearly understands how these 
sounds are produced the tendency is to regard each 
variation from the normal as pathognomonic of special 
disease, rather than dependent on changes in structure 
or function which may be present in conditions not 
necessarily pathologic. 

In this way only can diagnostic values be estimated, 
and the range and limitations of Physical Diagnosis be 
understood. 

Physical Diagnosis is now taught at an early period in 
the curricula of the medical schools, and this circum- 
stance has made it necessary to give a brief account of 
the morbid changes in different organs, and of their 
secondary effects, both immediate and remote. 

M 



vi PREFACE. 

In the preparation of this book I have gleaned freely 
from ..ilicr works on Physical Diagnosis, and from 
articles in the medical journals. 

I am indebted to Prof. C. G. Coakley and to my 
associate, Dr. S. A. Brown, for many valuable sugges- 
ting: to Dr. Eenry J. Prentiss, director of practical 
anatomy, for the chapter on Eegional . Anatomy, the 
production of many of the illustrations and the prepara- 
tion of the material for the radiographs of the bronchi; 
to Mr. Eugene W. Caldwell, director of the Edward K 
Gibbs Memorial X-Eay Laboratory, for the radiographs 
and for suggestions in chapter on Examination with X 
Ray; and to Dr. Titus M. Coan for valuable assistance 
while the work was going through the press. 



E. Le F. 



52 West Fifty-sixth St., New Yobk. 
September, 1902. 



CONTENTS. 

PAET I. 
ANATOMICAL. 

CHAPTER I. 
Regional Anatomy 17-36 

PAET II. 
THE RESPIRATORY SYSTEM. 

CHAPTER II. 
Inspection 37-57 

CHAPTER III. 
Palpation ■. 58-68 

CHAPTER IV. 
Percussion 69-95 

CHAPTER V. 
Auscultation 96-122 

CHAPTER VI. 

Auscultation (Continued) 123-140 

CHAPTER VII. 

Diagnosis of Diseases of Respiratory 
Tract 141-220 

PAET III. 
THE CIRCULATORY SYSTEM. 

CHAPTER VIII. 
Inspection . 221-232 

(vii) 



vi u CONTENTS. 

CHAPTER IX. 
Palpatio^ 233-25G 

CHAPTER X. 
IV \ 257-265 

CHAPTER XI. 
AlM TI.TATIOX 266-301 

CHAPTER XII. 
Diagnosis of Diseases of the Heart 302-351 

CHAPTER XIII. 
Diagnosis of Diseases of the Pericardium, 352-364 

CHAPTER XIV. 
I )iagnosis of Diseases of the Blood-vessels, 365-374 

PART IV. 
THE ABDOMINAL ORGAN'S. 

CHAPTER XV. 
I inspection 375-381 

CHAPTER XVI. 
Palpation 382-410 

CHAPTER XVII. 
Percussion 411-421 

CHAPTER XVIII. 
Auscultation 422-424 

PART V. 
Examination with X Ray 425-432 



PHYSICAL DIAGNOSIS. 



PABT I. 
ANATOMICAL. 



CHAP TEE I. 

REGIONAL ANATOMY. 

The following anatomical facts will serve as an aid 
to the location of thoracic and abdominal viscera. 

The trunk is divided by the diaphragm, or midriff, 
into two great cavities, the thorax and abdomen. 

The diaphragm is a muscular, tendinous structure, 
attached by its circumference to the ensiform cartilage, 
six or seven lower costal cartilages, the external and 
internal arched ligaments, and upper two or three 
lumbar vertebrae by two crura. It is inserted into a 
central trifoil tendon, and points convexly upward; 
therefore increasing the vertical diameter of the 
abdomen at the expense of that of the thorax. In 
moderate expiration this convexity reaches to the level 
of the fourth intercostal space on the right, and to the 
fifth on the left. This gives a general landmark for 
the base of the lungs and heart apex above, the upper 
limits of the liver and stomach below. 
2 



1 s . i.v.l TOMICAL. 

The limits of the thorax extend from the origin of 
the diaphragm to the apices of the lungs, a1 the level of 
the first dorsal vertebra behind, or one-half to one inch 
above the clavicles, but deeply placed behind the sterno- 
cleidomastoid muscles and scalenus anticus muscles. 

THE SUPERFICIAL LIMITS OF THE ABDOMEN. 

Above they are formed by the attachments of the 
diaphragm to the costal arches, etc.; below by the pubic 
hones, Poupart's ligaments and iliac crests. 

TEUE LIMITS OF THE ABDOMEN. 

The true limit above is the vault of the diaphragm; 
thai below is the floor of the pelvis, i c, levatores ani, 
etc. 

THORAX. 

The thorax is a conical-shaped structure, whose walls 
are: sternum and costal cartilages, anteriorly; ribs, 
laterally and posteriorly, and the twelve dorsal vertebrae 
in the posterior median line. Its floor is the dia- 
phragm; its apex is determined by the apices of the 
lungs, which are limited by the scalenus anticus muscles, 
beneath which the lungs project into the neck. The 
cavity is flattened from before backward, and above is 
reniform in shape on cross section, due to the marked 
anterior projection of the bodies of the dorsal vertebra*. 

The sternal Avail is obliquely placed, being nearer the 
posterior thoracic wall at its upper than lower limit. 

It begins at the episternal notch, opposite the second 
dorsal vertebra, and terminates at the ensiform cartilage, 
opposite the ninth dorsal vertebra. 

The vertebral wall begins at the first dorsal vertebra 
and ends at the twelfth; therefore the thoracic cavity is 
longer behind than in front, sloping downward and 
backward. 



REGIONAL ANATOMY. 19 



Surface Markings of Thorax. 

Anteriorly, Median Line. — Above is the episternal 
notch or jugular fossa, located between the sternal heads 
of the sterno-cleido-mastoid muscles and above the first 
piece of the sternum. Passing down, we come to the 
sternal groove or furrow. Its floor is the sternum, sub- 
entaneonslv placed, its lateral boundaries the sternal 
origins of the great pectoral muscles. Running the 
finger down this furrow, it comes to a marked ridge, the 
sternal angle, or angle of Ludovici. It is formed by the 
union of the first and second pieces of the sternum, and 
is opposite the articulation of the second costal cartilages 
— a valuable landmark in the counting of ribs. At the 
inferior extremity of the second piece of the sternum 
or gladiolus is located the infrasternal fossa (epigastric 
fossa or scrobiculus cordis). It is well marked, 
because of the prominent sternal articulations of the 
seventh costal cartilages and depression of the third 
piece of the sternum (ensiform or xiphoid cartilage). 

Laterally. — Passing from the first piece of the sternum 
almost horizontally outward and backward are the two 
clavicles, which overlie the first ribs. At the junction 
of the convex inner two-thirds with the concave flat 
outer one-third of the clavicles are felt the coracoid 
processes, projecting forward one-half to three-quarters 
of an inch from beneath the clavicles. Directly external 
to the coracoid processes we come to the upper extremi- 
ties of the humeri, their lesser tuberosity and bicipital 
ridge being directly under the finger. 

Above the clavicles are the supraclavicular fossae, 
into which the apices of the lungs project, but deeply 
placed beneath the sterno-cleido-mastoid and scalenus 
anticus muscles. Normally, these fossa? are shallow. 

Below the clavicles are the faintly marked infra- 
clavicular fossa?. Below the second ribs are the second 
intercostal spaces ; the right being called the aortic inter- 
space, the left the pulmonic. 



< > 



20 I A [TOMICAL. 

The nipples in the male and young females are 
usually found in the fourth intercostal spaces, about 
four inches from I he median line. 

Passing downward and outward from the junction of 
the gladiolus and ensiform cartilages are the deviations 
f the cartilages of the seventh, eighth, ninth ami tenth 
ribs, forming the subcostal angle, which is more acute 
in the ease of a long, narrow thorax. Running the 
finger down either side of this angle, we discover that 
the eighth costal cartilage is firmly attached to the 
seventh, while the ninth and tenth are freely movable, 
having a loose fibrous attachment to the cartilage above, 
instead of articular facets. The eleventh and twelfth 
ribs are felt below and behind the tenth. 

With the arms raised, the hands resting on the head, 
the axillary regions are exposed. The anterior and 
posterior borders of which, when continued vertically 
downward, form the anterior and posterior axillary 
lines; the vertical line midway placed is the mid- 
axillary line. It is in this region that the lnngs are 
nearest the examiner. 

Posteriorly. — In the median line is the vertebral fur- 
row, at the bottom of which can be felt the vertebral 
spines. This furrow is more marked in the cervical 
and lumbar regions than in the dorsal and sacral regions. 

Though the seventh cervical vertebra is called the 
vertebra prominens, the first dorsal spine is more promi- 
nent, projecting posteriorly perhaps one-fonrth of an 
inch further than the seventh cervical spine. Laterally, 
we come to the scapulae, located between the second and 
seventh dorsal vertebrae, thus simplfying the location of 
the ribs posteriorly. The spines of the scapula? meet 
their vertebral borders usually opposite the fourth 
dorsal vertebra. 

The vertebra] borders of the scapula are located about 
one and one-half to two inches from the median line, but 
deviating slightly towards the inferior angles. The 
interspace is called the infrascapula region. The region 



REGIONAL ANATOMY. 



21 



above each scapula spine is called the suprascapula 
region; below, the infrascapula region. 

Contents of Thorax. 
Trachea, two bronchi, two lungs, two pleura, heart, 

Fro. 1. 




Bronchi (child) filled with shot, No. 10. Diameter, .038 inch. Lateral view. 

with its pericardium, great vessels, oesophagus and 
thoracic duct. 

Trachea. — Four to four aud oue-half inches in length. 
Runs slightly obliquely from above downward and 



DO 



ANATOMICAL. 



backward a little to the right of the median lino. It 
begins a1 the cricoid cartilage of the larynx opposite the 
sixth cervical vertebra and terminates a1 its bifurcation 
into two bronchi opposite the fourth dorsal vertebra, or 
in the plane passing horizontally lYoin the junction of 



Fig. 2. 




,*•:"• 






Bronchi (adult) filled with shot. No. 1. Diameter. .110 inch. 

maubrium and gladiolus to the body of the fourth dorsal 
vertebra. (Plate IT ? and Fig. 1.) 

Bronchi. Right and Left. — Two,to two and one- 
half inches long from the bifurcation to where they 



L 

o 







REGIONAL AS ATOMY. 23 

break np into bronchia at the hilum of each lung. Each 
(Mitci's its respective hilum, the most posterior of the 
structures forming the lung root, i. c, two pulmonary 
veins, one pulmonary artery and one bronchus. They 
are in a plane anterior to the descending aorta, oeso- 
phagus, thoracic duet, etc. 

Right Bronchus. — Usually it has a greater lumen than 
the left, and is practically a continuation of the trachea, 
owing to the obliquity of the left bronchus. About one- 
half an inch from the bifurcation the right bronchus 
gives off a large branch, which passes to and supplies 
the upper lobe of the right lung, terminating above in 
apical branches. It crosses above the right pulmonary 
artery, and is therefore eparterial. 

All other branches of both bronchi are hyparterial. 

The right bronchus, considerably diminished in size, 
passes to the hilum, and continues in the lung substance 
downward and backward, to terminate in the angle 
between the diaphragm and posterior parietes. It gives 
off four sets of branches (antero-lateral and postero- 
lateral), alternately placed. The first anterolateral 
branch supplies the middle lobe ; the rest, the lower lobe. 

Left Bronchus. — The left bronchus passes more 
obliquely to the hilum of the left lung, and, entering the 
lung substance, terminates in the postero-inferior angle; 

It gives off no branches until entering the lung, and 
then gives off four sets — four ventro-lateral and four 
dorso-lateral — alternately placed. Its first ventro- 
lateral branch differs from that of the right bronchus, 
because it gives off a large ascending branch, which sup- 
plies the upper part of the left lobe to its apex. It is 
therefore the homalogue of the eparterial branch of the 
right lung. The continuation of the first ventro-lateral 
branch supplies the rest of the left upper lobe. 

The remaining; ventro-lateral and dorso-lateral 
branches supply the lower lobe. 

Referring to the X-ray picture of the bronchial tree, 
it is evident that more volume of sound passes down the 



' I ANATOMICAL. 

rjghl bronchus, because il has a greater lumen and is 
almost a conl inual ion of the t rachea. 

The eparteria] branch of the right bronchus arises 
just below the bifurcation, and, entering directly the 
righl upper lobe, distributes Its branches to the apex, 
passing through less Lung substance than is the ease 
with the ascending branch to the lefl apex. Therefore 
sound will be less modified on reaching the right apex 
than the left. 

As breath sounds arise in tlio larynx, and are modified 
by the decrease in the lumen of the air-passages and 
surrounding tissue, we will expect to find in the right 
apex persistence of the tubular quality of the breath 
s«»nnds. Such is the case, broncho-vesicular breathing 
being a normal condition on that side. 

Increased vocal fremitus in the right npper^ lobe 
normally is also explained by the above anatomical faets. 

Because the right bronchus is almost vertical, it is 
located in the right infrascapnla region, and explains 
why frequently broncho-vesicular breathing is heard in 
thai location. 

Lungs. Right axd Left. — Irregularly, pyramidal 
in shape. Each present an apex directed upward and 
placed deeply in the neek under the sealeni muscles; 
below, the base, deeply eoneave, resting on the dome of 
the diaphragm; an external snrfaee markedly convex, 
fitting into the concavity of the ribs; an internal sur- 
face, concave to permit the lodgment of the heart and 
great vessels; an anterior border, sharply defined, over- 
lapping the heart and great vessels; a posterior border, 
blunt, fitting into the concavity of the ribs between the 
posterior angles and the bodies of the first ten dorsal 
vertebrae. 

Each lung is divided into two great lobes by an 
oblique fissnre, which is practically constant. It begins 
posteriorly about three inches below the apex, and 
passes obliquely downward and forward on the external 
surface to the junction of the anterior border with the 



REGIONAL ANATOMY. 25 

base. They reach inward almost to the hilum of each 
lung. 

We see, therefore, that the upper primary lobe of 
each lung consists of the apex, anterior border and sur- 
face, while the lower primary lobe consists of the poste- 
rior herder, posterior surface and base. The upper 
lobe of the right lung is usually subdivided into two 
unequal lobes by a secondary fissure running from the 
anterior border obliquely downward and outward to the 
great oblique fissure, thus cutting off a small triangular 
lobe from the anterior surface. The anterior border of 
the right lung passes nearly vertically downward till it 
reaches its base. The anterior border of the left lung 
leaves the vertical nearer its base than apex, and passes 
obliquely downward and outward to reach the sharp 
c(]iXo of the base, thus uncovering a small triangular 
area of the heart. 

Surface Markings of Trachea, Bronchi and Lungs. — The 
trachea begins at the cricoid cartilage opposite the sixth 
cervical vertebra, and terminates deeply opposite the 
junction of the manubrium and gladiolus in front; 
fourth dorsal vertebra behind, or junction of the root of 
the spine of the scapula with its vertebral border when 
the scapula; 1 are normally placed. 

The bronchi enter the hilum of each lung about 
opposite the fifth dorsal vertebra. 

Lungs. — The apex of each lung reaches into the supra- 
clavicula fossa one to one and one-half inches above the 
clavicle, usually between the two heads of origin of the 
sterno-cleido mastoid. 

AxtepvTor Boeders. Right Luxg. — Its anterior 
border approaches the median line opposite the second 
eosto-sternal articulation, and continues downward in 
the median line to opposite the sixth eosto-sternal articu- 
lation, where it meets the thin margin of the base. This 
margin leaves the median line, passes backward with a 
gentle convexity, pointing downward, and finally joins 
the posterior border at the tenth dorsal vertebra. In 
the mid-axillary line it usually crosses the eighth rib. 






ANATOMICAL. 



Anteriob Bobdeb of Left Lung. — Reaches the 
median line opposite the second costo-sternal articula- 
tion ; continues downward in the median line to opposite 
the fourth costo-sternal articulation. At this point it 
leaves the median line and passes downward and out- 
ward towards the apex of the heart, located in the fifth 



Fig. 3. 




Relation of lungs, pleura, heart and liver to bony thorax. 

intercostal space, three and one-half inches to the left 
of the median line; and it continues to the sixth costal 
cartilage, where it reaches the thin basal margin. The 
latter then passes backward to the tenth dorsal vertebra, 
crossing the eighth rib in the mid-axillary line. 

Fissures. Eight Oblique. — Begins at fourth dor- 
sal vertebra, and passes downward and outward to the 
junction of the anterior border and base on the right 
seventh costal cartilage nearer its sternal articulation. 



REGIONAL A SATO MY. 



Vi 



Left Oblique. — Begins at third dorsal vertebra and 
passes downward and forward to near the junction of 
tho anterior margin and base, somewhere on sixth costal 
cartilage, external to the apex of heart. Therefore a 



Fig. 1. 




1 ^ tt r v- 

Relation of lungs, pleura, spleen and kidneys to bony thorax. 



smaller area of the left lower lobe presents anteriorly 
than the right lower lobe. 

Lesser Fissure of Right Lung. — It leaves the 
median line opposite the fourth costo-sternal articula- 
tion, and passes downward and outward to meet the 
great oblique fissure in the mid-axillary line at about the 
Bixth rib. (Figs. 3 and 4.) 



28 ANATOMICAL. 



PLEURA. 



There are two disl incl pleural sacs; one \'^r each lung. 
They have no relation with each other except at the 
junction of the anterior margins of the lungs, when they 
slightly overlap. 

Bach pleura] sac is divided into two portions, a 
viscera] and parietal. The viscera] pleura is in intimate 
relation with the lung wall, passing into the fissures. 
The parietal pleura is in intimate relation with the 
thoracic walls, pericardium, sides of great vessels, 
oesophagus, etc., as it leaves the under surface of the 
sternum to be reflected over these last structures in pass- 
ing to the posterior parietes. 

The parietal pleura becomes continuous with the 
viscera] pleura at the root of the lungs and downward 
to the diaphragm, thus forming a double fold of pleura 
running from the root to the diaphragm, and called the 
lateral ligament of the lung. The parietal pleura leaves 
the base of the lungs and projects into the costo-phrenic 
-inns, reaching to the twelfth dorsal vertebra posteriorly. 

Surface Markings of Pleura. 

The surface markings of the pleura is that of the 
parietal pleura. 

The right pleura begins at the apex of the right lung, 
one to one and one-half inches above clavicle. It reaches 
the median line opposite the second costo-sternal articu- 
lation, and continues vertically downward to the 
seventh costo-sternal articulation. It then crosses the 
seventh, eighth, ninth ribs, the tenth rib in the mid 
axillary line, and reaches the twelfth dorsal vertebra 
posteriorly. 

The left pleura begins at the apex, one to one and one- 
half inches above the clavicle; approaches the median 
line opposite the second costo-sternal articulation, and 
continues in the median line to opposite the fourth costo- 
sternal articulation. It then deviates, skirting the 



REGIONAL AS ATOMY. 2!) 

border of the sternum about one-half to one inch from 
its Left edge. It then has much the same course as the 
right. This deviation permits paracentesis pericardii 
withoul involvement of the pleura. 

HEART. 

The heart is a pyramidal-shaped organ of about the 
size of a man's fist. In the male it is five inches in the 
long diameter, three and one-half inches laterally and 
two and one-half inches antero-posteriorly. 

It presents an apex, base, anterior and posterior sur- 
faces, thin right border, due to the thin wall of the right 
ventricle, and blunt left border, due to the thick wall of 
the left ventricle. 

It is obliquely placed, its base looking upward, some- 
what backward and to the right ; its apex downward, 
somewhat forward and to the left. It is anchored by 
its great vessels, which spring from the base, and rests 
by its posterior surface on the diaphragm. 

The heart cavity is divided into four compartments: 
right and left ventricle, occupying the apical portion of 
the heart, and the right and left auricles, occupying the 
basilar portion. 

The ventricles are asymmetrically placed, owing to the 
intraventricular septum passing from the base obliquely 
downward to the thin right border one-half to three- 
fourths of an inch from the apex. 

The right ventricle consequently presents anteriorly, 
with its apex at the right thin border, nearer the 
sternum; while the left ventricle presents posteriorly, 
excepting its apex, which occupies the true heart apex, 
and therefore is farther removed from the sternum than 
the right ventricular apex. 

The right ventricle presents an atrium and infundi- 
bulum, or conns arteriosus ; the latter leading into the 
pulmonary artery. The left ventricle presents an 
atrium and aortic vestibule, the latter lying between the 
right mitral flap and ventricular septum. It is behind 
the infundibulum of the right ventricle. 



SO ANATOMICAL. 

Each auricle proem- an atrium and appendix. The 
righl auricle and appendix present anteriorly behind the 
sternum, and reaching to the righl of its right border 
from the third to the sixth costal cartilages. 

The lefl auricle presents posteriorly, its auricular 
appendix only presenting anteriorly behind the third 
rib aboul one and one-half inches to the left of the 
sternum. 

The anterior auriculo-ventricular sulcis is placed 
obliquely behind the sternum, reaching from the left 
third costo-sternal articulation to the right sixth eosto- 
sternal articulation. As the cardiac valves lie in the 
ventricular base, we see how their surface markings 
pracl Lcally tie in this Line. 

The arch of the aorta begins at the base of the left 
ventricle, behind the infundibulum of the right ventri- 
cle, and beneath the inferior angle of the left third costo- 
sternal articulation; it passes upward and towards the 
right one and one-half to two inches. At the upper 
angle of the second right costo-sternal articulation it 
sweeps backward toward the left side of the fourth 
dorsal vertebra to become the descending aorta. 

The pulmonary artery begins at the infundibulum of 
the right ventricle, behind the left border of the 
sternum, opposite the second interspace, and passes 
upwards, backward and to the left, where it bifurcates 
under the aortic arch into the right and left pulmonary 
branches. 



Surface Markings of Heart. 

Take a point on the lower border of the second costal 
cartilage, one inch from the left border of the sternum, 
and draw a line to the upper border of the third costal 
cartilage one-half inch to the right of the sternum. 
From this last point draw a line to the right seventh 
costo-sternal articulation, with a moderate convexity, 
pointing to the right. 



REGIONAL AS ATOMY. 31 

The apex is located in the fifth intercostal space, 
three and one-half inches to the left of the median line. 
Connect the left end of the base line with the apex, and 
the right seventh costo-sternal point with the apex, and 
we map out the entire area of the heart. 

To differentiate this area, connect a point behind the 
left third costo-sternal articulation with a point on the 
right sixth costo-sternal articulation. This plots out 
the aurieulo-ventricular sulcis. The heart area to the 
right of this line represents the position of the right 
auricle, the tip of its appendix being on this line 
opposite the third costal cartilage. The line running 
from the seventh right costo-sternal articulation to the 
apex of the heart represents the thin right border of the 
right ventricle. The left auricle is placed posteriorly, 
but its apex presents anteriorly at a point on the left 
convex line leading from the base to the apex, where it 
crosses the third costal cartilage about one and one- 
quarter inches from sternum. The continuation of this 
line represents the blunt left border of the left ventricle. 

The Location of the Valves. Pulmonary Valve. — 
It is beneath the upper angle of third left costo-sternal 
articulation. The valvular sound follows the course of 
the pulmonary artery to the pulmonary or left second 
interspace. 

Aortic Valve. — Lower angle of third left costo- 
sternal articulation, just behind left edge of sternum. 
Its valvular sound follows the course of the aorta to the 
aortic or right second interspace. 

Mitral Valve. — Behind the sternum, opposite 
fourth costo-sternal articulation. Its valvular sounds 
are carried to the apex of the left ventricle, or true apex 
of the heart. 

Tricuspid Valve. — In median line of sternum, 
opposite fourth intercostal space. Its valvular sounds 
are carried to the apex of the right ventricle, or just to 
the left of the ensiform cartilage. 

We observe that the valves are located nearly in the 



32 ANATOMICAL. 

plane of the auriculo-ventricular sulcis, the auriculo- 
vrentricular valves being located a little to the left of 
this surface marking, owing to the obliquity of hearl : 
the apex pointing more anteriorly, the base more 
l>< isteriorly. 

Superficial and Deep Areas of Cardiac Dullness. — The 
superficial area of cardiac dullness is that portion of 
the hearl uncovered by the lungs. It is triangular in 
area. The apex is above where the anterior borders of 
the two lungs separate in the median line opposite the 
fourth costo-sternal articulation. The right border of 
this triangle is the anterior border of the right lung, and 
therefore passes vertically downward in the median line. 
The left border is that of the left lung, and runs from 
the median line opposite the fourth costo-sternal articu- 
lation to the apex of the heart. There is no inferior 
boundary, as the cardiac dullness fuses with the liver 
dullness. The dee}) area of cardiac dullness is the rest 
of the heart outline. 

PERICARDIUM. 

.V pyramidal-shaped serous sac, inclosing the heart, 
and the aorta and pulmonary artery for one and one-half 
inches of their course and the superior vena cava; hut 
only partially enfolding the inferior vena cava. 

Its apex is directed upward, where the pericardium 
continues as a tubular prolongation on the great vessels. 
Its base rests on the diaphragm, blending with central 
tendon and extending over the left muscular portion. 
It is composed of two portions, an outer fibrous coat and 
an inner serous coat, the latter lining the fibrous coat 
and reflected downward on the great vessels to enfold 
the heart. 

The pericardium is attached to the sternum in front, 
and is in intimate relation with the parietal pleura, 
which is reflected upon it. It is covered by lung and 
pleura anteriorly, except for a small triangular area, 
where the left visceral pleura leaves the median line at 



REGIONAL ANATOMY, 66 

the fourth costo-sternal articulation to be deflected to the 
left about two fingers' width from the left border of the 
sternum. 

ABDOMEN. 

The abdomen is divided into three zones — epigastric, 
mesogastric and hypogastric — by two horizontal planes. 
The upper one runs antero-posteriorly at the lower 
limits of the tenth ribs, while the inferior one passes 
between the anterior superior spines of the ilia. These 
three zones are subdivided by two vertical planes erected 
from the mid-Ponpart points. The subdivisions are: 
right and left hypochondriac regions, which project 
behind the costal cartilages into the vault of the dia- 
phragm, and the epigastric region, triangular in shape, 
within the subcostal angle. The right and left lumbar 
and umbilical region, and, lastly, the right and left iliac 
or inguinal regions and the hypogastric or pubic regions. 

Liver. — The liver occupies the right hypochondriac 
region, part of the epigastric and the left hypochondriac 
as far as the mammary line. 

Its upper limits fit into the vault of the diaphragm, 
i. e.j fourth intercostal space on the right and fifth on 
the left. Its sharp anterior border passes obliquely 
from the right hypochondriac region and below to the 
left hypochondriac region and above, crossing the right 
costal border between the ninth and tenth costal carti- 
lage and the left costal border under the eighth costal 
cartilage. 

The fundus of the gall bladder, when distended, pre- 
sents under the right costal border where the lateral 
border of the right rectus abdominis crosses, or at the 
right ninth costal cartilage. 

Stomach. — The stomach, when moderately distended, 
presents a cardiac or oesophageal entrance; a cavity 
divided into a fundus, projecting into the left dome 
of the diaphragm; a body reaching downward to 
the plane separating the epigastric from the mesogastric 
3 



3 ! ANATOMICAL. 

zone and mi nut nun pyloris, which is located to the right 
of the median line. It finally opens by the pyloric 
opening into the first part of the duodenum. 

1 1 occupies, therefore, the left hypochondriac region 
mid a portion of the epigastric. The cardia and pyloris 
are deeply placed. The anterior surface rests against 
the anterior parieties. The stomach is in close relation 
with the liver superiorly, with the pancreas posteriorly; 
the left kidney and spleen to the left and posteriorly; 
the transverse mesocolon below. 

The surface markings of the stomach are: 

Cardiff. — Left seventh costo-sternal articulation. 

Fundus. — Reaches to fifth left intercostal space. 

Greater curvature reaches to line connecting tips of 
ninth or tenth ribs. 

Pylorus. — Just to right of median line, three and one- 
half to four and one-half inches below lower end of 
gladiolus. 

When moderately distended, a triangular area of the 
stomach is palpable in front. Its right boundary is the 
free border of the liver, passing from under the right 
ninth costal cartilage to the left eighth costal cartilage. 
The left border is the left costal border from the eighth 
to the tenth. Its lower limit is the greater curvature, 
on a line crossing between the ninth or tenth ribs. 

Spleen. — The spleen is in close relation to the 
stomach, being attached to its body by the gastro-splenic 
omentum. The spleen lies in the left hypochondriac 
region, but posteriorly placed. It extends between the 
ninth and eleventh ribs, its long axis running parallel to 
the left tenth rib. Its posterior limit reaches to within 
one and one-half to two inches of the vertebra, while its 
anterior limit extends to about the mid-axillary line. 

The spleen lies in the hollow of the diaphragm, its 
upper third having the lung interposed between it and 
the parieties; its middle third separated from the parie- 
ties by the costo-phrenic sinus, a space below the lung, 
between the diaphragm and thoracic wall. Its lower 



REGIONAL AX ATOM)'. 35 

third is in contact with the left kidney and tail of 
pancreas. We thus see that it is practically impossible 
to palpate the spleen under normal circumstances. 

Kidneys. Righ T and Left. — Retroperitoneal placed 
ohliquelv downward and outward on the posterior wall 
of the abdomen. The left is more superiorly placed, 
resting on the eleventh and twelfth ribs, and extending 
to within two and one-half to three inches from the iliac 
crest. 

The right extends from the upper border of the 
twelfth rib to within about two inches from the crest of 
the ilium. The lateral borders of the two kidneys 
extends beyond the lateral limits of the erector spina) 
muscles. 



PART II. 
THE RESPIRATORY SYSTEM. 



CHAP TEE II. 

INSPECTION. 

By inspection is understood the act of viewing the 
patient so as to learn all that may be observed by the 
sense of sight. Inspection is one of the most important 
methods of physical diagnosis, and all systematic exami- 
nations should begin with it ; and while it is not final, it 
is valuable in determining certain essential facts that are 
further differentiated by the other methods of physical 
diagnosis. 

The technique of inspection is as follows: 

(1) The patient should be stripped of clothing as far 
as possible. In children and in the male adult all 
clothing should be removed from the chest except that 
which may be necessary to avoid chilling of the sur- 
face; in the female, delicacy may demand that the 
patient be thinly covered, but wherever it is required 
the examiner should not hesitate to demand that the sur- 
face be bare, if only a part at a time, so that correct 
observations may be made. Where for any reason it is 
impossible to bare the chest thoroughly, much of the 
observation that would ordinarily be made by inspection 
must be made by palpation. 

(2) Inspection may be made with the patient either 
standing, sitting or in the recumbent posture, according 
to the circumstances of the case. 



'" s THE RESPIRATORY SYSTEM. 

When the patienl is able, the standing or sitting 
posture is preferable, inasmuch as it is easier for the 
observer, and the movements of the chest are not inter- 
fered with. The patienl should assume a natural or 
customary posture. Usually as soon as inspection is 
commenced they try to assume a "correct" posture. 

(3) li is accessary that the light fall equally on both 
sides, as the value of inspection is in the comparison of 
one portion of the chest with the corresponding portion 
of the opposite side. The observer generally stand- 
directly opposite the patient, so as to have both sides 
within the range of vision. Where it is necessary to 
determine slight variations in the upper portion of the 
thorax, it can often be best done by the observer stand- 
ing behind the patient and looking over the shoulder 
and downward along the clavicle and upper ribs. This 
will show the slightest degree of depression in these 
areas. 

NORMAL CHEST. 

The size of the normal chest varies within wide 
limits, and also with the age and sex of the individual. 
In determining whether or not its variations are within 
the normal limits, it is necessary to consider the general 
physique of the patient, as the size of the thorax should 
bear a definite relation to height and weight. 

It is extremely difficult to describe a perfectly normal 
chest. The thorax should be well developed, although 
it is only one in four persons that have perfectly and 
symmetrically-developed chests. The neck should bear 
certain definite relations to the bony thorax, and, 
according to the general physique of the patient, the 
neck will be long or short and its relations will vary 
according to the development of the upper portions of 
the body. 

The direction of the clavicles varies with the indi- 
vidual. In the broad, square-shouldered individual they 
lie almost in a horizontal plane, while in those with 
sloping shoulders the outer border tends to slope down- 



INSPECTION. 39 

wards and backwards to meel the tip of the shoulder 
blade. Above the clavicle there is, normally, a slight 
depression, called the supraclavicular depression. The 
depth of this depression varies in individual cases, and 
whether or not it is normal can only be judged by com- 
paring it with the general contour of the chest. Encrease 
in the depth of the depression above the clavicle occurs 
in those conditions which cause diminution of the size 
of the apex of the lung', interfering with its normal dis- 
tension when the thorax is enlarged in respiration. 
These conditions may affect the entire lung, causing 
general contraction of the chest, as in general pulmonary 
fibrosis, etc., or may affect the apex only of one or both 
lungs. While a number of diseases may cause this local 
condition, the most important is pulmonary tuberculosis. 

The sternum normally is carried forward and down- 
ward from its junction with the clavicle. At the junc- 
tion of the upper and middle portion of the body the 
so-called angle of Louis is formed. This varies in 
individual cases, and is increased in certain diseases of 
the respiratory tract. 

The ribs curve forward and meet the sternum so as 
to give a gradually increasing depth to the chest from 
above downwards. There is also a gradual increase in 
the angle with which they join the sternum from above 
downwards. At the epigastric notch the angle is well 
marked, and its acuteness varies with the general con- 
tour of the chest. 

The intercostal spaces are of a definite width, accord- 
ing to the shape of the thorax. They should be slightly 
depressed, and in a well-developed thorax are visible 
only in the lower portions. 

Posteriorly, the scapula lies flat upon the ribs, and 
the spine is, normally, slightly curved toward the right 
side. 

The physiological departures from the perfect chest 
have been variously described as long and short, broad 
and narrow, deep and hollow. All these variations, 



LO THE RESPIRATORY SYSTEM. 

though quite consistenl with health, may give the 
student greal difficulty in determining whether or nol 
they are within the range of normal. 

As the development of the chesl varies greatly in dif- 
ferent individuals, many chests are seemingly Indicative 
of some intrathoracic diseases which depend upon non- 
development of the bony thorax and of the lungs during 
the maturing peri d of life. 

How can it be determined if the shape, form and size 
of the chest is within the range of normal for the indi- 
vidual under observation I 

This can be done only by taking into consideration 
not only the thorax, but the entire bony skeleton as well, 
and determining if the thorax harmonizes with it. The 
social status of the individual, the general physique, 
occupation, etc., must be fully considered. Faulty 
habits of posture may cause slight asymmetry of the 
bony thorax without in any way influencing the function 
of the contained organs. The observer must not form 
the inference that each departure from the ideal thorax 
is pathological, but must note the variations from the 
normal, and by the other methods of physical diagnosis 
determine if there is any change in the location, struct- 
ure or function of the underlying thoracic organs. 

Deviations from the normal chest have been classified 
as follows : 

PATHOLOGICAL CHESTS. 

(1) The Barrel-shaped, or Emphysematous Chest. — In 
this form there is an increase in all of the diameters of 
the chest, especially marked in the antero-posterior. 
The chest assumes a type more nearly approaching that 
-ecu in the infant. (Fig. 5.) The position is one of 
full, forcible inspiration. The clavicle and sternum 
are carried upward and forward by the action of the 
auxiliary muscles of inspiration ; the neck is shortened ; 
the infraclavicular spaces may be deeper than normal, 
shallower, or may be even projecting. The scapula^ are 



INSPECTION, 



41 



thrown upwards, outwards and forwards, and project 
from the rounded thorax. The normal antero-posterior 
curvature of the spine is increased. 

Bilateral or uniform enlargement is most frequently 
caused by pulmonary emphysema (large lung) ; it occurs 
also during attacks of asthma (temporary emphysema), 
bilateral pleurisy with effusion, hydro-thorax and 
cancer (rare). 

(2) The Phthisical, Paralytic, Alar, or Pterygoid Chest. 
— In this type there is. an abnormal flattening of the 

Fig. 5. 




Bilateral enlargement of emphysema. 
Outer line = a circle drawn to show how nearly the emphysematous 

approaches the circular shape. 
Dotted line = natural adult chest. 
Inner line = emphysematous chest. 

Actual measurement in centimetres 
Circumference = natural, 89.0 emphysematous, 87.75 

Transverse = " 29.6 " 27.25 

Antero-posterior = " 22.25 " 25.4 (Dr. Gee.) 



sternum and ribs, so that the antero-posterior diameter 
of the chest is diminished and there is a slight increase 
in the lateral diameter. (Fig. 6.) 

The depression of the ribs and of the sternum carries 



L2 



THE RESPIRATORY SYSTEM. 



the sterna] end of the clavicle downwards, lengthening 
the neck and causing the chin to projecl farther forward 
than normal over the anterior plane of the thorax, giving 
a characteristic appearance t<> the individual. 

The jingle of the plane of the clavicle with the scapulae 
ami sternum alters the depressions above the clavicles, 
increasing their depth. The intercostal space- are 
deepened; the shoulder blades are depressed and stand 
out from the ribs, giving the winged appearance (alar, 
or pterygoid). 

The movements on quiet breathing may be nearly 
normal in frequency and extent, but on exertion or 

Fig. 6. 




15 c 



The flat or phthisical chest, short antero-posterior, long transverse 
diameter. (Gee.) 



forced breathing expansion is less than normal, and 
the movements become more rapid. 

This type may be simulated in marked emaciation by 
diminution in the soft parts which normally give the 
rounded contour to the upper portion of the chest. Lack 
of muscular development, or changes in the muscles of 
respiration, such as occur from long recumbence in bed, 
cause slight depressions of the bony thorax, due to feeble 
inspiratory efforts. Symmetrical depressions of the 
thorax in the above conditions are easily differentiated 
from those dependent upon pathological intrathoracic 



INSPECTION. ! ; > 

conditions by noting that the normal contour of the bony 
fchorax is preserved, although there may be a slight 
flattening of the chest. 

The pathological conditions which lend to produce the 
phthisical type of chest are thickening of the intercostal 
pleura, which interferes with the elevation of the ribs, 
and widening of the intercostal spaces during inspira- 
tion ; thickening of the pulmonary pleura preventing the 

Fig. 7. 




Transverse section of a rachitic chest at level of sixth thoracic vertebrae. 
Circumference, '32% inches; right half, 16% inches; expansion, 2 inches. 



normal expansion of the lung; changes in the lung 
which diminish its elasticity, as tubercular induration, 
fibrosis, etc., and the closure of the bronchi, which pre- 
vents the entrance of air into the lung. 

(3) The Rachitic Types. — In the simplest form there 
is a flattening laterally of the chest, especially in the 
lower segment; while in the upper portion the sternum 
is carried forward and the ribs are more or less straight- 



44 



THE RESPIRATORY SYSTEM. 



ened, so that the antero-posterior diameter of the chesl 
is increased above, while the lateral diameter is dimin- 
ished below. (Fig. 7.) From this simple type the 
diameters greatly increase up to the so-called "pigeon- 
breasted" type. ( Fig. 8.) In this form the sternum 
is pushed forward; "the ribs arc straightened out at 
their angle and at their junction with the cartilages," 
so thai a section of the chesl is aearly triangular and the 
whole contour resembles that of the breast of a pigeon. 
Rachitic chests also frequently show nodular enlarge- 
ments at the junction of the bony ribs with the carti- 
lages, which have been named the rachitic rosarv. 

Fio. B. 




Circumference =42.75 centimetres. 

Rickety chest. Dotted line indicates the shape of chest in an infant about 
the same age. (Gee.) 



(Fig. 9.) The depressions and peculiarities of the 
rachitic chest are due to intercurrent attacks of bron- 
chitis, involving the smaller tubes and causing interfer- 
ence with the entrance of air into the alveoli, and the 
production of a partial vacuum during inspiration. The 
effect of atmospheric pressure and the action of the 
diaphragm is to depress the soft and yielding thorax. 

Frequently, near the junction of the fifth rib with 
the sternum, and running obliquely across the chest, 
there is a well-marked depression or groove, which has. 
been named the Harrison furrow. The occurrence of 



46 



THE RESPIRATORY SYSTEM. 



Harrison's furrow and the deformities that occur in the 
lower portion of the chest as a result of the action of 
the diaphragm are closely related to that phenomenon 
known as Litten's sign, which will be later described. 

In the departures from normal above mentioned 
there is a certain want of symmetry between the two 
sides, but, as the changes are bilateral, they are gener- 
ally classified as symmetrical deformities. 

Ficx. 10. 




ST75 •-. ■ 



,--''20 



16 'S 



Unilateral enlargement of chest (right side) artificially produced by injecting 
air into the right pleural cavity. Unbroken line: outline before injection. 
Broken line: outline after moderate distension. Dotted line: outline after 
extreme distension. Figures at bottom of vertical line indicate the antero- 
posterior diameter ; along horizontal line, transverse semi-diameter; remain- 
ing figures, right and left semi-circumference. (Gee.) 



The chest also presents unilateral or asymmetrical 
enlargement and retraction, which may affect an entire 
side or a portion only. The unilateral deformities may 
be dependent upon spinal curvatures, congenital and 
occupation deformities, swelling or oedema of soft parts, 
or to intrathoracic changes. 

Unilateral Enlargements. — Unilateral enlargements are 
most readily seen when the patient is viewed from 



INSPECTION. 47 

the front. On the affected side the clavicle is higher; 
the supraclavicular space may be deeper or shallower, 
according to the cause. The mammae may be displaced 

outwards, with widening' of the intercostal spaces, which 
may be shallow or bulging, according to the condition 
present. From behind the spine is curved toward the 
enlarged side, and the scapula is carried outwards. 
Movement on the affected side may be increased, dimin- 
ished or absent. (Fig. 10.) The intrathoracic causes 
of unilateral enlargement may be due to 

(1) Compensating emphysema. In this condition 
the lung of the enlarged side is performing more work 
than normal, and is receiving not only its own quota of 
air, but also that which should be received by the 
opposite side. When due to this cause, the increased 
action of the muscles of inspiration are plainly visible, 
and the intercostal spaces are deepened with each 
inspiration; the action of the diaphragm is increased, 
and movements on the larger side are exaggerated. 

(2) General unilateral enlargement of the chest may 
be due to filling of the pleural cavity with air (pneumo- 
thorax), fluid (pleurisy with effusion), pus (empyema), 
dropsical effusions (hydrothorax) or solid tissue. 

In enlargements due to diseases of the pleura, not 
only is the size of the chest enlarged, but the depressions 
of the intercostal spaces are diminished, obliterated, or, 
in extreme cases, may be bulging. There is also marked 
depression of the diaphragm and protrusion in the epi- 
gastric region; and the movements of the affected side 
are diminished or absent. 

(3) Unilateral enlargement of the thorax may be 
induced by a lobar pneumonia affecting an entire lung. 

Care must be taken, wdien there is marked asymmetry 
of the thorax, in determining the relative changes that 
have taken place in the two sides, whether or not the 
enlargement of one side is absolute and abnormal, or, 
on the contrary, whether it appears to be longer than 
normal because of unilateral diminution of the opposite 
side. 



18 



THE RESPIRATORY SYSTEM. 



Unilateral Diminution in Size. — Til this condition the 
affected side is smaller in all dimensions. (Fig. 11.) 
The ribs are closer together; the intercostal spaces are 
narrowed, and may even be obliterated, or the ribs, in 
extreme cases, may overlap each other, especially in the 
lower portion. The ribs are more oblique than nor- 
mally, giving that side of the chest a longer and 
narrower appearance. The mamma is nearer the median 

Fig. 11. 




Unilateral retraction of chest, consequent upon cirrhosis of left lung-, in a 
girl of fourteen years. The figures indicate antero-posterior and transverse 
diameters and semi-circumferences of right and left half of chest. (Gee.) 



line ; the top of the shoulder is lower than its fellow on 
the opposite side; the scapula is thrown nearer to the 
spinal column, and the spinal column is curved, the 
convexity looking towards the opposite side. The 
movements of the affected side are diminished, re- 
stricted, or may even be absent. The supraclavicular 
fossa is deeper than normal. 

Unilateral diminution in size may be due to (1) 
primary arrest of development, as occurs in infantile 



INSPECTION. 49 

hemiplegia, etc., when the asymmetry is not limited to 
the thorax alone, but generally extended over the entire 
lateral half of the body; and the affected side, although 
-mailer than the opposite, preserves its normal physio- 
logical features. 

Unilateral diminution in size also occurs when there 
is atrophy or loss of function of the muscles of normal 
inspiration. In this condition retraction of the side 
could only occur when the condition had lasted for a 
long time, and the unopposed traction or negative press- 
ure of the lung had been sufficient to cause a gradual 
depression of the ribs. 

( 2 ) Diseases of the Plettr.e. — Marked retraction 
of the thorax occurs in diseases of the pleura?, especially 
after absorption of the fluid in pleurisy with effusion, 
when changes occur in the lung or in the pleurae which 
prevent the lung thoroughly filling the thorax, as pul- 
monary collapse and fibrosis and chronic thickening of 
the pleura, adhesions of the two surfaces of the pleura. 

( 3 ) Changes in the Lungs. — These include changes 
in the lung which cause a diminution in its size, as 
chronic interstitial pneumonia (fibrosis, cirrhosis of the 
lung), tuberculosis, interference with the entrance of 
air into the lung through narrowing or occlusion of the 
lumen of the bronchi of entire lung. 



LOCAL BULGINGS. 

The asymmetry of the chest may be due to changes 
that affect a limited portion of the chest only. 

Limited enlargements may be due to (1) changes that 
occur in the soft parts, as swellings or tumors, lipomas, 
malignant growths, etc. 

(2) Diseases involving the bony thorax itself, as peri- 
ostitis or exostosis, fractures of the bony thorax, or from 
localized deformities due to spinal curvature, distortion 
of the ribs, with enlargement of one side, the front of 
4 



50 THE RESPIRATOR V SYSTEM. 

which is compensated for by a corresponding increase 
of the opposite side behind. 

(3) A bulging of a limited portion of the chest wall 
may he produced by a localized or encapsulated collec : 

linn of fluid or air within the pleural cavity. The 
amount of deformity that such a collection may produce 
is directly dependent upon the conditions of the bony 
thorax, being most marked in early childhood, when the 
chest wall is soft and yielding, very slight effect or none 
being produced on the rigid chest wall of adult life. 

(4) Bulging of the thorax over the precordial space 
may occur as a result of cardiac enlargement, or of 
pericarditis with effusion. The amount of bulging will 
depend upon the condition of the chest wall, the same as 
was mentioned above. Dilatation of the large vessels 
may also cause local bulgings, which may be attended 
with visible pulsation. Local bulging of the bony 
thorax in aneurism does not occur until the pressure of 
the dilating vessel has been sufficient to cause a soften- 
ing of the overlving' bones. 

(5) Enlargements of the lower zone of the thorax 
may be caused on the ri&lit side bv enlargement of the 
liver, and on the left side by enlargement of the spleen. 

(6) General enlargement of both sides of the lower 
portion of the thorax below the fifth rib may be pro- 
duced by anything that increases the intra-abdominal 
pressure, as meteorism, ascites, abdominal tumors reach- 
ing the diaphragm, etc. 



LOCAL DEPEESSIONS OR RETRACTIONS 
OF THE CHEST. 

These may be produced (1) by diseased conditions of 
the soft parts, as local wasting in the muscles of a part. 
If there is paralysis of the muscle, so that its action 
upon the ribs is interfered with, the constant negative 
pressure that is exerted by the lung may be sufficient to 
cause a slight depression or retraction over the affected 



INSPECTION. 51 

area. (2) Disease of the bony structures, as rachitis. 
(3) Changes in pleura, as thickening, adhesions. (4) 
It may be dependenl upon a disease of pulmonary tissue, 
as tuberculosis, fibroid induration and other pathological 
conditions which render it less distensible. 

It is neeessarv at this point to have a clear idea of the 
factors that produce localized depressions in diseases of 
the lung and pleura. In normal inspiration, Avhen the 
thorax enlarges as a result of muscular action, the dis- 
tensible lun<>' readily fills the cavity. When, on the 
other hand, a change occurs within the thorax, affecting 
the pleura or the pulmonary tissue, either as a result of 
tubercular infiltration or fibroid induration, on inspira- 
tion the affected portion of the lung does not readily 
enlarge, and as a result there is a tendency to produce a 
vacuum at the point affected. In the early stages a 
compensatory dilatation of the surrounding alveoli may 
make up for this lack of distensibility of the lung, but, 
on account of the gradually-developing muscular weak- 
ness and constant action of the atmospheric pressure 
over the affected part, there is produced the character- 
istic depression or retraction of localized intrathoracic 
diseases. 

In diseases of the pleura, characterized by adhesions 
and obliterations of the sac after the absorption of the 
fluid in pleurisy with effusion, with atelectasis of the 
lung, and in resection of the rib, these factors may 
cause a retraction of the entire side. 

RESPIRATORY MOVEMENTS. 

In addition to changes that occur in the form and 
size of the chest, the movements of respiration are to be 
noted. Difficulty may be experienced in getting patients 
to breathe properly. Under examination they are apt to 
breathe abnormally, and in certain nervous individuals, 
if they are conscious of observation, it is impossible to 
get a true idea of the respiratory movement. These 



52 THE EESPIB. 1 TOE Y SYSTEM. 

individuals should be observed without attracting atten- 
tion to your purpose. 

Normally, the movements of the two sides are equal 
and simultaneous. With each inspiration the upper 
portion of the chest is well filled out; there is a move- 
ment upward and outward of the ribs; an increase in 
the vertical, transverse and antero-posterior diameter 
of the thorax ; depressions of the intercostal spaces are 
increased, and there is a protrusion of the abdomen in 
the epigastrium, due to the descent of the diaphragm. 
With expiration the movements take place in the reverse 
order. 

The movements of inspiration are active, depending 
upon the action of the muscles on the bony thorax, 
increasing the size of the thoracic cavity with the pas- 
sive distension of the lung. In expiration the move- 
ments are caused by the elasticity of the overdistended 
lung, aided by the elastic tension of the entire thorax 
and the weight of the chest. 

Three types of respiration are recognized as physio- 
logical : 

(1) The costal, or superior costal, which is seen 
chiefly in women. In this type the movements of the 
upper portion of the chest are most marked; there is 
little expansion of the lower segment of the thorax, and 
the protrusion of the abdomen is slight. In this type the 
sternum as a whole is elevated. Elevation of the 
sternum occurs both in quiet and deep breathing in 
women, but in man only in deep breathing. 

(2) The inferior costal in which the most marked 
movement occurs in the lower six ribs, and the dia- 
phragmatic phenomena are more markedly noticed. 
This is the type of breathing normal for an adult male. 

(3) The diaphragmatic or abdominal breathing which is 
chiefly present in children. 

In determining whether the movements of respiration 
are normal, therefore, it is necessary to take into account 
the sex and age of the patient. 



INSPECTION. 53 

Costal breathing may be abnormally increased (1) 
when the movements of the lower segment of the thorax 
or diaphragm are interfered with by oedema or inflam- 
mation of the lower lobes of the lungs, preventing their 
expansion, in which case the exaggerated costal breathing 
is compensatory. (2) Pleurisy with effusion, involving 
both pleural sacs. (3) Diseases of the bony thorax, as 
Pott's disease, or painful affections which interfere with 
the movement of the ribs on both sides. 

(4) Painful affections of the soft parts, although they 
rarely affect both sides. (5) Paralysis of diaphragm, 
due to bulbar paralysis, neuritis of the phrenic nerve 
in multiple neuritis, hysterical neuroses. When the dia- 
phragm does not act there is absence of protrusion of 
the epigastric region, with inspiration, and it may be 
replaced by depression, which is especially noticeable 
in hysterical paralysis and diaphragmatic pleurisy. 
(6) Diseases below the diaphragm, with pain on move- 
ment of the abdominal organs, as peritonitis, general or 
local. (7) Increased abdominal pressure from ascites, 
tympanites or tumors, which mechanically prevent the 
descent of the diaphragm. 

The inferior costal and diaphragmatic breathing may 
be increased by any condition that prevents or inter- 
feres with the normal costal breathing, as consolidation 
of the upper lobes of the lung from any cause, painful 
affections involving the pleurae, intercostal nerves, or 
bony thorax. It is especially diagnostic if it replaces 
normal costal breathing in the female adult, except in 
old age. In proportion as there is a lack of expansion 
of the bony thorax and the movement of the ribs is 
interfered with, there is a corresponding action of the 
diaphragm and diaphragmatic, or abdominal breathing. 
In old age the bony thorax becomes more rigid, and 
increased abdominal breathing is present in the female 
as well as in the male. 

The movements may be increased unilaterally when- 
ever there is interference with the respiratory function 



54 THE EE8PIR. I TOR V SYSTEM. 

of the opposite side. This condition is compensatory, 
the increased action of the unaffected side making 

up as Ear as possible for the absence of function of the 
other. 

Increased Kespiratory Movements. — The movements of 
respiration are increased in extent and number in con- 
ditions of dyspnoea, which may be due to (1) diseases 
of the lungs, which diminish their vital capacity, as 
bronchitis with exudation, consolidations of the lung 
from various causes, diseases of the pleura?. (2) 
Cardiac diseases, in which there is imperfect aeration of 
the blood from deficient circulation. (3) Diseases of 
the blood, in which its power to take up oxygen is 
diminished (anaemia), (4) Nervous diseases, in which 
there is no defect in oxygenation, but rather an increased 
irritability of the respiratory centers. (5) In those dis- 
eases in which there is an increase in the elimination of 
C0 2 , as seen in fevers, etc. 

Distinction is made between exaggerated breathing, 
or increased motion, in which the ordinary muscles of 
respiration only are involved, and labored breathing, 
where the extraordinary muscles of respiration are 
called into play. 

Diminished respiratory movement may be bilateral, 
unilateral or local, and may occur as a result of (1) dis- 
eases of the muscles of respiration, (2) painful condi- 
tion of soft spots, (3) diseases of the bony thorax, (4) 
diseased conditions of the pleurae or (5) in diseased con- 
ditions of the lung, either general or local. 

Bilateral diminution, or absence of motion, occurs 
when there is disease of the bony thorax, especially 
Pott's disease, preventing a normal movement of the 
ribs. Also in diseases involving the intercostal nerves 
and muscles. It is present, with enlargement of the 
thorax, when both pleural cavities contain air or fluid ; 
when the elasticity of the lung is diminished, as in 
emphysema ; after absorption of fluid in pleurisy or 
empyema ; with thickening and adhesion of the pleurae 



INSPECTION. •>•> 

in diseases of the lungs which prevent or interfere with 
this expansion. 

Whenever there is difficulty or interference with the 
entrance of air in the lung, through narrowing or occlu- 
sion of the upper air-passages or bronchi, as a result of 
forced inspiratory effort, there is a marked depression 
of the lower portion of the thorax, due to the partial 
vacuum that is produced. Not only is motion inter- 
fered with, but the number of respirations is diminished. 

Unilateral and local diminution of motion varies in 
degree from slight lagging to entire absence of motion, 
and may be due to loss of muscular power; to painful 
conditions of the muscles (inflammation, neuralgia) ; 
of the bony thorax (periostitis, fracture of ribs, etc.) ; 
to diseased conditions of the pleurae (acute pleurisy, 
painful and catchy breathing), or increased thickness 
and adhesions preventing movement of ribs and expan- 
sion of lung. These conditions are associated with 
unilateral and local retraction. When the pleura con- 
tains air and fluid, loss of motion is associated with 
increase in size. 



LITTENS PHENOMENON. 

In addition to the protrusion of the epigastrium, 
Litten has called attention to the effect that descent of 
the diaphragm has on the lower portion of the chest. 
If a person who is not too fat is so placed that lying on 
his back the light fall upon the chest from the direction 
of the feet only, the observer, standing at the side, 
notices a narrow shadow moving downward when a full, 
dee]) breath is taken. This shadow is due to expansion 
of lower ribs, caused by the slow separation, by the 
descent of the diaphragm, of the two surfaces of the 
pleura over the so-called complemental spaces and the 
gradual extension of the lower border of the lungs, with 
rilling out of the intercostal spaces. 

The phenomenon is modified or absent in all condi- 



56 THE RESPIRA Ton Y SYSTEM. 

tions that (a) change the normal relation of the 
two surfaces of the pleura in the complemental space, 
viz., effusion into the pleural cavity, pneumonia of the 
base of the lung, pulmonary emphysema; (b) or inter- 
fere with the descent of the diaphragm, as adhesions of 
the two surfaces of the pleura ; or (c) prevents the lung 
from distending as fibroid induration and tubercular 
infiltration, especially of the apex. 

Litten's phenomenon is often of value in diagnosing 
slight pleuritic effusions from enlargements of the liver 
and spleen, as subdiaphragmatic conditions do not inter- 
fere with the descent of the diaphragm, unless attended 
with pain or greatly increased intra-abdominal pressure. 

ALTERATIONS IN FREQUENCY. 

Rapidity of respiration varies normally with age. 
Under one year of age it is 44 per minute ; one to five 
years, 26; five to twenty years, 20, and after twenty 
years of age the average rapidity is 18. Physiologi- 
cally, it is influenced by posture, exercise, digestion and 
by mental influence. In diseases of the respiratory 
tract the rate is increased in proportion to the inter- 
ference with the aerating function of the lungs. The 
rate in diseases of the lung is never decreased, except 
laryngeal or tracheal stenosis and asthma. 

Diminution in the rate of respiration is otherwise 
dependent upon some influence acting on the nervous 
system, and especially on the respiratory center. 



ALTERATION IN RHYTHM. 

Normally, the movements of breathing are in perfect 
rhythm, each respiratory act being of equal length and 
depth and following each other without any appreciable 
pause. The movement of inspiration is slightly shorter 
than that of expiration, the ratio being as 5 to 6. As 
age advances this ratio becomes slightly greater, due to 



INSPECTION. Oi 

the impaired elasticity of the lung, so that in the aged a 
ratio of 5 to 8 is not unusual; 

In asthma and emphysema the rhythm is disturbed in 
proportion to the expiratory difficulty, so that the move- 
ment of inspiration may be short, spasmodic or jerky, 
while expiration is slow, prolonged and incomplete. 

When obstruction of the upper air-passages (intra- 
laryngeal or intratracheal growths, false membranes, 
etc.) produce inspiratory dyspnoea, then the inspiratory 
movements are prolonged and the breathing is slow. 

The rhythm is also disturbed when the respiratory 
movements cause pain (intercostal neuralgia, pleuro- 
dynia, pleurisy, etc.), and, as the pain is most intense 
at the time of greatest motion, the inspiration is short, 
shallow and catching and expiration slow and feeble. 

A peculiar disturbance of rhythm has received the 
name of "Cheyne-Stokes" breathing. The movements 
are unequal and arhythmical, but follow a fixed cycle. 
One or two shallow respirations are followed by four or 
five that progressively increase in frequency, depth and 
noise until the acme is reached, and then gradually sub- 
side in inverse order. This is followed by a longer or 
shorter respiratory rest or "pause" (apnoea), which is 
followed by another attack of disturbed breathing. 

This type of breathing occurs in severe types of 
cerebral, cardiac and renal diseases and narcotic poison, 
and is generally an unfavorable symptom. 



CHAPTER III. 

PALPATION. 

By palpation we obtain information by the sense 
of touch, or tactile sense, and it is usually the second 
step in the examination of the respiratory and circula- 
tory organs. 

While it confirms all that has been learned by inspec- 
tion, it is in many respects more definite and exact, and 
increases the evidence that has already been obtained 
by the eye, for it determines the presence or absence of 
certain vibratory phenomena and allows of differential 
diagnosis between conditions that produce similar 
changes in the shape of the thorax. 

As inspection furnishes results of a general character, 
so also does palpation, and, on account of the ease with 
which it is performed, we often substitute it for inspec- 
tion where that is impossible on account of the posture 
of the patient to view the chest. 

The results obtained by palpation depend upon the 
sensitiveness of the observer's sense of touch (tactis 
eruditus) y and whether or not the chest is examined in 
a methodical and systematic manner. 

Every part of the thorax should be examined, and 
those who claim that palpation is of minor importance 
are either deficient in the sense of touch or employ it 
in a haphazard manner without attention to details. 

In performing palpation the surface should be bare, 
so the hand can be applied directly to the skin. It 
is not necessary to expose the thorax to view, as the hand 
can be slipped under a loose covering. At times it may 
be necessary, on account of a feeling of delicacy on the 



PALPATION. - r >9 

pari of the patient, to have a lliin covering, as gauze, 
between the surface and the hand, but even this inter- 
feres with the examination to a certain extent. The 
hands of the examiner should he warm, so as not to be 
unpleasant to the patient. 

Attention should be paid to the position of the 
patient, and the examiner should always bear in mind 
that want of symmetry is a matter of greatest impor- 
tance, so that the two sides should be compared region 
by region, as each portion of the chest gives its own 
evidence. 

By palpation of the thorax, with reference to the 
respiratory organs, knowledge is gained of the follow- 



(1) SIZE, SHAPE AND SYMMETRY OF THE THORAX. 

Palpation gives very little information on these points 
beyond what can be gained by inspection, and in most 
cases it is not as accurate in regard to symmetry. When 
inspection is impossible, on account of not being able 
to expose the chest, we gain a fairly accurate knowledge 
by palpation. 

One important fact noted by palpation is the loca- 
tion of the different ribs. Remember that the second 
rib is the one below the clavicle, that can be taken 
between the fingers ; it corresponds with the ridge on 
the sternum. 

(2) RESPIRATORY MOVEMENTS. 

As its object is to test if the movements of the two 
sides are simultaneous and equal, it is necessary that 
the hands be placed over corresponding regions of the 
chest for comparison. 

As the time, extent and rhythm of the respiratory 
movements are to be examined, also whether the widen- 
ing of the intercostal spaces occurs equally on both sides, 
the hands must be so placed as to note these points. 



GO THE RESPIRATORY SYSTEM. 

To palpate the anterior surface of the chest, the 
examiner stands behind the patient and places the hands 
over the chest so that the fingers are parallel with the 
ribs, resting in the intercostal spaces. By these means 
a belter perception of motion and of time is obtained. 
T<> palpate the posterior surface, the position is reversed. 

The antero-posterior movement of the chest is 
noted by placing one hand over the sternum in front, 
and the other posteriorly over the spine. 

The movement of the clavicle and upper ribs is 
observed by placing the hand over the shoulder, the 
fingers resting on the anterior portion of the chest, and 
the thumb behind on either side of the spine. 

The examiner should remember that the respiratory 
movements are influenced by age and sex, as already 
explained under "Inspection." 

Slight inequality of motion between the two sides, as 
shown by a slight lagging of one side, when present in 
the slightest degree, is detected by the expert palpator, 
and is of diagnostic importance. 

Under "Inspection" attention was called to Litten's 
phenomenon. The action of the diaphragm that pro- 
duces it can be felt as well as seen, and gives us impor- 
tant evidence of any change in the movement of the 
diaphragm. 

Palpation is almost as sensitive as the fluoroscope in 
detecting slight changes in diaphragmatic movement. 



(3) VIBRATORY PHENOMENA. 

Vocal fremitus, also called tactile and tussive fremi- 
tus, are the vibrations that are felt by the hand on the 
surface of the chest when the air contained in the lungs 
is thrown into vibrations sufficiently strong to be trans- 
mitted to the thorax and recognized by the sense of 
touch. The vibrations of ordinary respiration are too 
feeble to be appreciated by the hand, while they are 



PALPATION, CI 

recognized by the ear and termed normal vesicular 
murmurs, or breath sounds. 

In order to obtain vibrations sufficiently powerful, 
the voice is used. The movements of the vocal cords 
sel up corresponding vibrations in tlic air contained in 
the lungs, which are transmitted through the thorax 
and appreciated by the hand on the surface of the chest. 

Vibrations set up by the voice are not of equal 
strength for all persons, varying according to the voice, 
sex and age of the individual. The wave length in man 
is from 8 to 12 feet ; in women, 4 to 6 feet, while in the 
child the wave length is so short and the vibrations so 
rapid as to render vocal fremitus indistinct. 

As the character of the vibrations produced by the 
voice modify the vocal fremitus that is obtained, it is 
necessary that the vocal vibrations be as equal and as 
uniform as possible. For this reason the patient is 
usually instructed to count 1, 2, 3 or use some phrase, 
as 99 or 44. Any monotone may be employed to set up 
the vibrations. 

It must be borne in mind that each individual will 
have his own vocal fremitus, which will have a direct 
relation to the character of his voice. Voices that are 
low pitched and heavy, as in man, give a correspond- 
ingly strong vocal fremitus; while, on the other hand, 
the thin, weak or high-pitched voice, as in woman, being 
an octave above that in man, gives a correspondingly 
weak vocal fremitus, which in some cases may be so 
faint as not to be detected by touch. 

The vibrations produced in the larynx do not reach 
all portions of the surface of the chest with equal 
intensity. We note that it is stronger over the right 
lung than over the left ; that it is more marked over the 
right apex than over the left. 

The reason for this difference in intensity is explained 
by the anatomical arrangement of the primary bronchi 
on the two sides and their relation to the trachea. The. 
bronchus going to the right lung is more nearly a con- 



G2 



THE RESPIBATOBY SYSTEM. 



tinuation of the trachea, has a greater lumen, and, in 
addition, leaves the trachea at a less acute angle, so that 
the vibrations thai arc se1 up in the larynx reach the 
entire right lung with greater force, on account of the 
larger column of air contained in the bronchi. 

Pig. L2. 




The situation of the bronchial tree emphasizes the fact that vocal fremitus 
is obtained more distinctly over the right than the left lung-, greater in the 
upper than the lower thorax. 



Vocal fremitus over the apices of the two lungs differ, 
being more intense on the right side. 

This physiological increase of vocal fremitus on the 
right side often misleads the observer, as its intensity 
may suggest a pathological condition of the lung. 

The cause of this marked increase of vocal fremitus 
over the apex of the right lung is due to the fact that 
the bronchus supplying the upper lobe is given off from 



PALPATION. 06 

the primary bronchus close to the trachea, and the vibra- 
tions conveyed to the upper lobe of the right Lung arc 
correspondingly stronger. Whether or not this increase 
is pathological can only be determined by considering 
other signs in connection with it. 

The nearer the bronchi approach to the surface of the 
lung, and the larger their lumen, the more distinct will 
the vibrations be felt. For this reason the vibrations 
are stronger over the upper portion of the thorax, 
between the scapula behind, especially on the right side, 
and at the junction of the second intercostal spaces on 
the right side and the third on the left. (Fig. 12.) 

The further the surface of the chest is removed from 
the larynx and trachea, the smaller the bronchi that sup- 
ply the portion of the lung immediately underlying it, 
the greater the proportion of pulmonary tissue to the 
bronchi, the weaker will be the vibrations that are con- 
vey ed from the larynx to the surface of the chest, and 
consequently the vocal fremitus that is felt over the 
lower portion of the thorax and nearest the extremities 
of the lung is much weaker than over the large bronchi. 

In addition to the influence of the pulmonary struct- 
ure, the vocal fremitus is modified by the condition of 
the chest wall ; and, according to the law that vibrations 
are lost in passing through media of different densities, 
and especially when passing from a media of a lesser to 
one of a greater density, vocal fremitus will be weak 
over those portions of the chest where a large amount of 
tissue intervenes between the hand and the pulmonary 
structure. 

This is especially marked over the mammae in women, 
over the scapula behind and is uniformly modified over 
the chest when the soft parts are greatly increased in 
thickness. 

It is very necessary that the examiner should bear in 
mind the normal variations of vocal fremitus that occurs 
over different regions of the chest, and that he thor- 
oughly familiarizes himself with their relative intensity. 



G 1 THE RESPIRA TOR V SYSTEM. 

In examining for vocal fremitus the whole hand is 
placed lightly upon the chest, so as to get a relative idea 
of the vibrations over the point that is examined. It 
will make a difference whether the fingers are placed in 
the intercostal spaces, as in testing for the respiratory 
movement, or on the ribs and bony thorax. 

When the fingers are placed between the ribs, then 
the vocal fremitus that is felt is transmitted from the 
pulmonary tissue directly through the thin covering of 
the intercostal spaces, while if the hand is placed upon 
the ribs, or, as is usually done, across the ribs and 
intercostal spaces, then the vibrations that are felt are 
not those that are conveyed to the surface by the portion 
of the lung immediately under the hand, but are all the 
vibrations that have been brought to the surface and 
have been taken up by the bony thorax, which acts as a 
sounding board. 

In order to examine for vocal fremitus in a limited 
area, it is best to place the tips of the fingers only upon 
the chest in the intercostal spaces while the patient is 
speaking. In this way slight local variations may be 
readily detected. 

When the hand is placed over the shoulders, the 
thumb resting behind and the tips of the fingers beneath 
the clavicle, we obtain an idea of the relative intensity 
of the vocal fremitus that is produced in the entire 
upper portion of the thorax. 

Vocal fremitus may be increased, diminished or 
absent. 

Vocal Fremitus Increased. — As was seen above, under 
Normal Variations in Vocal Fremitus, the vibrations 
that are made in the larynx are modified by the con- 
ducting power of the lung, and are normally weakened 
as they pass from the larger to the small bronchi, and 
from these to the alveoli. 

As the "spongy" condition of pulmonary tissue inter- 
feres with the transmission of vibration, so, on the other 
hand, any condition which renders the lung more homo- 



PALPATION. bo 

geneous gives an increased power of conduction, and 
consequently increases vocal fremitus. 

Increased vocal fremitus is obtained in all pulmonary 
consolidations, such as those of pneumonia, tubercular 
infiltration, infarction or fibroid thickening of the lung; 
and the amount of vocal fremitus is directly dependent 
upon the changed anatomy of the lung and its increased 
power of conduction. 

As the vibrations that are brought to the surface are 
transmitted through the columns of air contained in the 
lung and the pulmonary structures, the tension of the 
lung tissue will modify the transmission of these vibra- 
tions. 

Increase of tension increases the ease with which the 
vibrations are carried from one portion of the lung to 
the other, and also increases the rapidity of the vibra- 
tions themselves. 

Increase of tension is present in pulmonary conges- 
tion, causing a slight increase in vocal fremitus. 

In children, in addition to the high-pitched voice, 
with its attendant rapid vibrations, the tense pulmonary 
tissue causes the vibrations to become so rapid as to be 
indistinct. 

Increased vocal fremitus is felt over cavities in the 
lung, as the vibrations from the larynx, trachea and 
bronchi are transmitted direct through the large air- 
containing spaces to the surface of the chest. 

Diminished or Absent Vocal Fremitus. Changes Due 
to the Bronchi. — As the vibrations are conveyed 
chiefly through the columns of air in the bronchi to the 
surface of the lung, anything that diminishes the lumen 
of the tube would interfere with the transmission of the 
vibrations from the larynx in direct proportion to the 
diminution in size. If it is occluded, aerial vibrations 
are arrested, and there is an absence of vocal fremitus 
over the area supplied by the occluded bronchus. 

Vocal fremitus may be diminished through narrow- 
ing of the lumen of the tube in bronchitis and asthma, 
5 



CC THE RESP1BA Toll V SYSTEM. 

and may bo entirely interfered with in plugging of the 
bronchi, as occurs in fibrinous bronchitis, in pneumonia, 
or by the growth of tubercle nodules; and also by occlu- 
sion of the tube by pressure, as in aneurism. 

Changes Due to Pulmonary Tissue. — Just as 
tense pulmonary tissue by vibrating in unison with the 
air in the bronchial tubes increases the amount of vocal 
fremitus, so all conditions which render the lung tissue 
less tense interfere with the transmission of vibrations 
to the surface by smothering or absorbing the vibrations 
conveyed to it. This is especially noticeable with loss 
of elasticity and negative pressure in emphysema, while, 
on the other hand, it does not occur in compensatory 
emphysema, where the tension of the pulmonary tissue 
is increased, as in this condition the vocal fremitus may 
be normal, the increase of tension in the pulmonary tis- 
sue counterbalancing the increased sponginess from 
dilation of the alveoli. 

Ixfluexce of the Pleura. — Ordinarily the normal 
pleura, on account of its extreme thinness, has no influ- 
ence on vocal fremitus. When, however, the pleura is 
thickened, or it contains effusion of any kind, it inter- 
feres markedly with the transmission of the vibrations 
from the lungs, according to the law that vibrations are 
lost when they pass from a rarer to a denser medium, 
and the amount lost, ranging from a slight diminution 
in intensity to total absence, will be in direct proportion 
to the amount of thickening or fluid that is contained 
within the pleural cavity. 

The conditions of the pleura which interfere with the 
transmission of vibrations are: (1) Pleuritic thicken- 
ing, which may be due either to primary pleurisy or be 
dependent upon tubercular infiltration: (2) Exuda- 
tions upon the surface of the pleura, as occurs in acute 
pleurisy with plastic exudation: (3) Effusion into the 
pleura, whether serous, sero-fibrinous or purulent. The 
specific gravity of the fluid does not alter to an apprecia- 
ble degree the transmission of vocal fremitus. (4) 



PALPATIO*. 67 

When the pleural cavity contains air, as in pneumo- 
thorax, the vocal fremitus is interfered with, because 
the relaxed lung is a poor conductor of vibration. 

Influence of the Chest Wall. — Increase in the 
thickness of the soft parts will diminish vocal fremitus, 
according to the law that vibrations are lost in passing 
from a rare to a dense medium, but not to the same 
degree as a corresponding thickness of the pleura. 

The reason for this is that when the pleura is thick- 
ened the vibrations are smothered or suppressed before 
they can be conveyed to the bony thorax, which acts as 
a sounding board and overcomes to a certain degree the 
inertia of soft (thickened) tissues of the chest wall. 

This diminution will occur especially if the source 
of vocal fremitus, namely, the voice, is of such a nature 
as to give normally a feeble vocal fremitus. 

Rhonchi and Palpable Rales. — In addition to the vibra- 
tions that are produced by the voice, the air passing 
through the liquid secretion in the bronchi is frequently 
thrown into vibrations sufficiently strong to be conveyed 
to the chest wall as fremitus. On account of being 
made in the bronchi, they have been named bronchial 
rhonchi, or palpable rales. 

They occur chiefly with inspiration, and are most 
frequently felt in children; and are usually associated 
with noisy or asthmatic breathing, but the ordinary 
sibilant or sonorous rales of asthma are so high-pitched 
and the vibrations are so rapid that they are not detected 
by sense of touch. 

Friction Fremitus. — Ordinarily the surface of the se- 
rous membranes glide over each other without friction. 
When, however, there is a marked roughening of the 
two surfaces, then their movement may be attended 
with vibrations sufficiently intense to be felt on the 
surface. 

Friction fremitus is most commonly felt at the point 
of greatest motion of the serous membranes, normally 
in the axillary space over the fifth and sixth ribs. 



6 8 THE BESPIRA TOR Y SYSTEM. 

Splashing or Succussion Fremitus. — When air and fluid 
are contained in the pleural cavity, and rarely in large 
cavities in the lung lying close under the pleura, on 
coughing or violent shaking of the chest the motion of 
the fluid contents may be sufficient to be felt on the sur- 
face. 

Pain. — In addition to the vibratory phenomena, it is 
possible to determine by palpation whether or not pain 
is present. 

Pain on palpation may be due to a sensitive condition 
of the chest wall itself, as is seen in the tender spots of 
Valleux, in inflammatory conditions of the muscular 
tissue and in diseased conditions of the bony thorax, as 
periostitis, etc. 

An important variety of pain elicited by palpation is 
interpleural. In order to test for this it is necessary 
that the pressure be made so forcibly as to interfere with 
local expansion of the chest and bring the two surfaces 
of the pleura into close contact. The sign is valuable 
in tubercular involvement of the pleura over the apex. 
It is obtained by standing behind the patient, bringing 
the hands over the shoulder, as in testing for vocal 
fremitus, and making firm pressure with tips of the 
fingers in the infrascapular fossa. 

Frequently it is possible to obtain this slight sign 
when no pleuritic rales can be detected by auscultation. 

The test for pain, and especially interpleural pain, 
should be left till the last, as, if it is performed earlier 
in palpation, it is apt to disturb the rhythm and move- 
ment of the thorax, and so lead to false impressions. 

Fluctuation. — By palpation we also determine the 
consistency and elasticity of tumors and enlargements 
of the chest that have been noted on inspection. 



CHAP TEE IV. 

PERCUSSION. 

Percussion in physical diagnosis is the act of strik- 
ing the body in order to elicit sound by setting up 
vibrations. 

If the tissues that are percussed are solid, as the 
thigh, the sound produced will be dull, and is described 
as toneless, flat or dead. If, on the other hand, it con- 
tains air or gas, as the thorax or abdomen, it gives out a 
sound that has resonance or tone and the elements of 
sound — (1) quality or timbre, (2) intensity or volume, 
(3) pitch, (4) duration or length— will be present and 
easily recognized by the ear. 

It is necessary to consider the elements of sound in 
detail, so as to appreciate their value in the percussion 
of the thorax. 

The quality or timbre of a sound is "that character- 
istic by which the sound produced from some particular 
source, as from an instrument or voice, may be dis- 
tinguished from sounds from other sources, instruments 
or voices." 

It is physically dependent upon the form of the vibra- 
tions by which the sound is produced, and although the 
pitch, intensity and duration may alter, the quality still 
indicates the source of the sound. 

The quality of the sound produced by percussion over 
lung tissue is called pulmonary or vesicular resonance. 

The intensity or volume of sound depends upon the 
amplitude or extent of the vibrations. It varies directly 
as their square, and is further modified by the force of 
the blow. 



TO THE RESPIRATORY SYSTEM. 

The intensity is influenced in pulmonary percussion 
by the amount of the air-containing tissue that is set in 
motion. It is also modified by the surrounding tissues, 
whether or not they are easily thrown into vibration 
when struck, and so impart motion readily to the con- 
tained air. Therefore, in the percussion of the thorax 
the intensity of resonance is influenced by the condition 
of the chest walls, bony thorax and pulmonary tissue. 

The influence of the force of the blow and the amount 
of air contained and the nature of the covering is 
readily illustrated in the drum. While the quality of 
the sound does not change, the intensity or volume is 
directly in proportion to the force of the blow upon the 
drum head. 

The pitch depends upon the rapidity and length of 
the vibrations. The shorter and more rapid the vibra- 
tions, the higher the pitch. This is well illustrated in 
the fiddle string or drum head. The pitch becomes 
higher when the tension of the vibrating medium is 
increased, and is lowered by relaxing it. 

The pitch is the most difficult part of a sound to 
appreciate, because the ear does not note slight varia- 
tions in pitch as readily as changes in quality, intensity 
or duration, and it is only by training the ear that the 
finer changes are recognized. 

Beginners are confused by the fact that high pitch is 
most frequently associated with dullness, and therefore 
it seems impossible to distinguish between a high-pitched 
note which is dull or characterless, as over-consolidated 
lung, and a resonant, clear note that is also high 
pitched, as occurs over distended lung tissue with 
increased tension. 

Within certain limits, pitch varies in the lung accord- 
ing to the tension of the tissues, but, as this is slight, it 
can only be considered in connection with the other ele- 
ments of sound. 

The pitch of the percussion note over normal lung 
tissue is low, varying within narrow limits in different 
individuals. 



PEMCUSSION. 71 

As pitch depends riot only upon the rapidity and 
length of the vibrations of the air in the pulmonary 

tissue, hut also upon the facility with which the vibra- 
tions pass through the tissues, the different notes we 
obtain in percussion of the thorax are modified by the 
soft parts of the chest, the bony thorax and the patho- 
logic conditions in the pleura and pulmonary tissue. 

From a diagnostic standpoint, variation in pitch is 
the most important of all changes that occur in the per- 
cussion sound, as it shows the physical condition of the 
part percussed. 

The duration of sound depends upon the length of the 

Fig. 13. 



Flatness. 

\ 

\Dull tone. 

\ 

_\Tracheal or tubular tone. 

_\ Resonant tone. 

. ^Tympanitic tone. 



Volume and duration. 
Diagrammatic sketch of the relations of the character of tone. The perpen- 
dicular line represents the pitch. The transverse line the 
volume and duration. 

waves and their persistence, and varies directly with 
the pitch and intensity. 

The elements of sound have a definite relationship to 
each other. (Fig. 13.) Sounds that have the highest 
pitch have the least intensity and minimum duration 
and resonance. Such a sound is described as flat or 
airless. 

As the pitch becomes lower the intensity increases, 
duration lengthens, quality of resonance becomes more 
marked and the sound is described as dull, resonant or 
tympanitic, according to the pitch. 



72 THE RESPIRATORY SYSTEM 

Normal pulmonary resonance has a quality character- 
istic enough to be easily recognized, although impossible 
to describe, low pitch, great intensity and duration. 

It is this combination of the elements of sound that 
is described by the "clearness" of the note. 

As these elements vary, the various pathological 
types are produced. 

METHODS OF PERCUSSION. 

In order to elicit sounds from the air-containing 
spaces of the lungs by percussion, vibrations are set up 
in the chest in a number of different ways : 

(1) Immediate, or Direct Percussion. — This was first 
used by Auenbrugger, in 1761. In this method the 
blow is struck directly upon the chest wall, generally 
over the bony structures. The sound produced is 
chiefly that made by striking the bony thorax, and its 
value is to show the ease with which the thorax itself is 
thrown into vibration. Light immediate percussion 
over the clavicle is especially sensitive in showing slight 
differences in resonance at the apex of the lung in begin- 
ning tuberculosis when no change can be detected by 
mediate percussion. 

(2) Mediate, or Indirect Percussion. — In this method 
the blow is struck not directly upon the thorax, but upon 
some interposed medium, which is called the pleximeter. 
In this country a finger of the left hand, either the index 
or the second, is generally used as the pleximeter, but 
some examiners use in its place pleximeters made of 
various substances, as ivory, wood or other material that 
has a certain amount of elasticity. 

It is important that the student become familiar with 
a single method. If he is constantly substituting for 
the finger the ivory or wood pleximeter, he does not 
become proficient in any one method, and is confused by 
the sounds elicited. Ordinarily one of the hardest 
things for the student to ignore in percussion is the 



PERCUSSION. to 

sound produced by striking the pleximeter, which, in 

instruments made of ivory, etc., is especially marked, 
and is one of the chief objections to their use. 

The linger, on the contrary, has a structure homo- 
genous with that of the thorax, and does not add a new 
quality to the percussion note. After a certain amount 
of practice, this sound is ignored, and only that which 
is elicited from the deeper portion of the thorax noted. 
As a pleximeter, the fingers give a wider range in size 
and shape, and readily adapt themselves to the surface 
of the thorax. 

It is a matter of choice which finger of the left hand 
is selected for this purpose, as all have been advised, 
but whichever is selected, that one should always be 
used. The other fingers and the hand should be raised 
from the chest so as not to dampen the vibrations. The 
finger used should be applied firmly enough to hold the 
soft parts in place and to leave no space between the 
finger and the soft parts, as this will give an impure or 
"cracked-pot" sound. 

In addition to the above advantages, the finger also 
allows the examiner to note the resistance of the tissue 
percussed and any lack of vibration, so that in percussing 
the chest one frequently feels more than he hears. 

Accurate comparative percussion requires that the 
finger be applied to corresponding spots on the tw r o 
sides. If percussion on one side is over the rib or inter- 
space, it should be made over the same tissues on the 
opposite side, and the same amount of pressure should 
be used. 

To obtain the purest pulmonary resonance, the finger 
should not be placed upon the bony thorax, but in the 
interspace. The reason for this will be considered 
later. 

That with which the blow is struck is called the 
plessor. For this purpose may be used the finger or 
fingers of the right hand, or a small hammer of ivory, 
wood or some other elastic substance. Many hammers 



74 



THE RESPIRATORY SYSTEM. 



have been advised, and the virtues of each one has been 

extolled by the inventor, but all are inferior to the finger, 
although proficiency in finger percussion is harder to 

attain, and demands no little practice. Ordinarily the 
failure to appreciate the value of percussion as a means 
of diagnosis is due to imperfect technique. The fingers 
are bent in a crooked and uneasy position; the whole 
arm is then moved, and the blow is struck from the 
elbow. This blow is necessarily a heavy one, and, on 
account of the infrequency with which it is struck and 

Fig. 14. 




Showing- position of fingers in percussion. 



the length of time that the percussing finger rests upon 
the pleximeter, suitable vibrations are not set up in the 
chest wall. 

To get the clearest sounds, it is necessary that the 
fingers be bent from the second joint, so that the tips of 
the fingers are even, and they must strike squarely and 
quite vertically upon the pleximeter. The blow should 
be struck entirely from the wrist, and should be a short, 
sharp tap, the percussing finger or fingers resting but a 



PERCUSSION. 



i o 



short time upon the finger si ruck. (Fig. 14.) Light 
percussion can be performed by a motion of the finger 
only. Care should be taken by the beginner that the 
nail of the hammer finger does not strike directly upon 
the underlying finger. The blow should be struck with 
the rounded end of the finger, just as it curves to meet 
the palmar surface. 

A good way of obtaining the wrist motion is by plac- 
ing the entire arm flat upon the leaf of a table and strik- 
ing it from the wrist from forty to eighty times a 

Fig. 15. 




minute. (Figs. 15 and 16.) The resonant table leaf 
readily shows by the sound any variation in the force or 
frequency of the blow. It is well also for the student to 
stand close to a wall, facing it, and, applying the arm 
to the wall, perform the same motions, so as to accustom 
himself to percussing in different positions. 

The rapidity with which the blow is struck has a 
marked influence upon the amount of sound produced. 
In certain cases single blows, with long intervals 
between, are used for the purpose of determining the 



7G 



THE RESPIRATORY SYSTEM. 



ease with which the thorax is thrown into vibration. 
When they are struck with medium rapidity (but not 

less than forty to the minute), the vibrations reach the 
deeper portion of the lung with equal strength and a 
clear note is obtained. When the blows are struck too 
rapidly, there is an accumulation, so to speak, of vibra- 
tions, and there occurs an interference of the sound 
waves. 

The force of the blow should be the same over corre- 
sponding portions of the two sides. 

Fig. 16. 




A correct position for the patient is almost as impor- 
tant as the technique of the operator. The surface 
should be bare, but if this is undesirable, then the 
covering should be as thin and soft as possible. Males 
do not object to being stripped to the waist for examina- 
tion, but in the female, and especially the young, it is 
best to have the surface protected by a soft, thin dress, 
sack or shawl. 

Whether standing, sitting or lying, the patient should 
assume a perfectly easy and natural position, with the 
muscles relaxed and the positions of the two sides 



PERCUSSION. i I 

symmetrical. While the standing posture is the most 
convenient I'm- the examiner, it is best to examine 
patients who are weak in either the sitting or lying 
position, as the pressure of the finger on the chest is apt 
to cause them to sway, or, to prevent this, they brace 
themselves, and so cause uneven tension of the muscles 
of the two sides. In examining patients in bed, care 
should be taken that the body is straight and the shoul- 
ders not unevenly placed. 

It should be remembered that when the patient is in 
bed and surrounded by pillows, the character of the per- 
cussion sound will be somewhat changed, being slightly 
muffled ; also that the percussion outline of the organs is 
modified by their "passive mobility." 

When percussing the front of the thorax, the patient's 
arms should hang easily at the side, and the head should 
be held straight in the median line. The patient, in 
order to avoid breathing in the examiner's face, fre- 
quently turns the face sharply to one side, rendering 
percussion above the clavicle difficult, and the result- 
ing tension of the muscles changes the sound of the 
two sides. To percuss the axillary space, the arm 
should be moved slightly backward, or raised at a right 
angle to the body, with the hand resting on the head, so 
as to relieve the tension of the muscles. 

When percussing the back, as the heavy muscles and 
scapula interfere with the pulmonary tissue underneath, 
the shoulder blades are carried forward toward the 
axillary space by folding the arms across the chest, with 
the tips of the fingers resting on opposite shoulders. 
Or, when sitting, the arms may hang loosely between 
the knees, allowing the shoulders to drop forward as 
much as possible. These positions uncover a large por- 
tion of the thorax, and the line of the scapula corre- 
sponds to the lower border of the upper lobe and inter- 
lobular septum. 



7$ THE EESPIE. I TOR V SYSTEM. 



CONDITIONS MODIFYING PERCUSSION SOUND. 

As the object of percussion is to elicit sound from the 
deeper portion of the thoracic cavity, it is necessary to 
consider the influences that the different structures have 
upon the vibrations that are set up. 

(1) Influence of the Soft Parts. — The ease with which 
the soft parts are thrown into vibration depends largely 
upon their structure. Muscular tissue, on account of 
its tension, is easily influenced, so that, with the bony 
thorax chiefly covered with muscle, vibrations are 
readily conveyed to the deeper portions of the chest. 
On that part of the thorax where the muscle tissue is 
heavy, blows that would be sufficient to set up vibrations 
in the air-containing spaces below the thinly-covered 
portion are absorbed by the heavy muscle, and no sound 
is heard. 

Adipose tissue, on account of its lack of elasticity, is 
thrown into vibration with difficulty, while (edematous 
tissue is the most difficult of all to influence by ordinary 
percussion. The effect that the soft parts have upon 
vibration is clearly shown in Fig. 17. 

In order to overcome this interference of the soft 
parts with the transmission of vibration, it is necessary 
that the percussion be more forcible, as shown in Fig. 
17. 

It is thus easily perceived that percussion of the same 
strength will not elicit the same sound over all portions 
of the chest, irrespective of the condition of the lung 
itself. Where muscle or adipose tissue is thinnest a 
fairly good pulmonary resonance may be obtained with 
light percussion, while, on the other hand, where the 
muscle or fat is thick, as over the mammse and the heavy 
muscles of the back, very forcible percussion is neces- 
sary, and the sound obtained is the dull, high-pitched 
note of the solid structures with little pulmonary 
resonance. 

The student must be on his guard to differentiate 



PERCUSSION. 



70 



between dull, high-pitched notes that are obtained by 
percussion over the thick soft parts from the dullness 
that is duo to intrathoracic changes. 

(2) The Influence of the Bony Thorax. — Bony tissue, 



Fig. 17. 




1, 2 and 3 represent the difference of result of percussion notes of equal 
strength, but with different body thicknesses. 3 and 4 show how by increasing 
the force of the blow lung resonance is obtained. 



S THE R ESP IRA TOR V S) r 8 TEM. 

when thinly covered, gives a peculiar note of its own 
when struck. The bony thorax is easily thrown into 
vibration, and if the blow be struck upon a rib the vibra- 
tions that are set up are not only transmitted to the 
viscera underneath, but are conveyed along the ribs to 
the sternum and other bony portions of the thorax. 

The readiness with which the bony thorax takes up 
vibrations must also be considered in the force of the 
blow. If the blow r is very forcible, the whole of one 
side of the thorax may be thrown into vibration, and 
then, instead of obtaining sound from the portion 
immediately underneath the part struck, vibrations are 
obtained from the whole of the thorax, the sternum act- 
ing as a sounding board. Forcible percussion over the 
clavicle, on account of the conveyance of the vibrations 
to the sternum and through it to the general thorax, is 
used merely to indicate the condition of one side of the 
chest as compared with the other, and is of little value 
as indicating the condition of the tissue immediately 
underneath it. A marked consolidation of one lung, or 
a collection of fluid in the pleural cavity, makes the 
percussion of the clavicle on the affected side much 
duller. 

Percussion over the sternum is resonant, with a 
peculiar bony note. The sternum acts as a sounding 
board, and is influenced to a slight extent only by the 
normal underlying tissue. When the normal resonance 
of the sternum is diminished and a dull sound is 
obtained, it shows that these vibrations are interfered 
with by intrathoracic conditions, that replace the ante- 
rior edges of the lung, solid growths in the mediastinum, 
by fluid accumulations in pericardium, or by aneurysmal 
dilatation of the aorta. 

The ease with which the bony thorax is thrown into 
vibration varies at different periods of life. 

In the child, on account of the flexibility of the ribs, 
vibrations are easily conveyed to the underlying lung, 
and a clear, well-defined pulmonary resonance is 



PEBCUSSION. 81 

obtained, scarcely modified by the sound given off by the 
bony thorax. Percussion in children should, therefore, 
be light, otherwise diffuse vibrations are set up and reso- 
nance is obtained from a large extent of lung tissue. 

As the hones of the thorax become more rigid, cspe- 
cially in old age, the bony sound becomes more marked, 
and there is a raising of pitch, so that it is described as 
a boardy or wooden note. 

(3) Influence of the Pleura. — The normal pleura has 
practically no effect on the vibrations produced by per- 
cussion, but pathological changes which cause thickening 
influence them in a marked degree. 

On account of the close relation that the pleura bears 
to the ribs, a very slight thickening is sufficient to inter- 
fere with the vibrations that are set up by percussion of 
the overlying structures. This is detected not only in 
the sound elicited, but in a peculiar "hard feeling" 
imparted to the fingers. The ordinary springy condi- 
tion is changed to one of increased resistance, and 
varies in degree according to the characters of the 
changes in the pleura. 

When the thickening is caused by new tissue homo- 
geneous with the pleura, then its influence is slight. 
If, however, a thick layer of plastic exudation covers the 
surface, then the dullness w T ill be in direct proportion to 
its thickness. 

A collection of fluid within the sac renders the note 
flat, the feeling being similar to that noticed when the 
thigh is struck. 

In order to determine whether or not the variation in 
the resonance is due to pleuritic thickening or to changes 
in the pulmonary tissue, the effect of percussion of dif- 
ferent degrees of force must be used. 

Light percussion will be markedly influenced by 
slight pleuritic thickening, while in very forcible per- 
cussion the vibrations are so strong as not to be inter- 
fered with to any appreciable extent. This is shown 
in Figs. 18 and 19. 
6 



82 



THE RESPIRATORY SYSTEM. 



(4) Influence of the Pulmonary Tissue. — The resonance 

that is obtained from the thorax is duo to the lung being 



an air-containing 



and the elements of sound 



depend largely upon the condition of the tissues of the 
lung itself and the amount of air contained. 




1 and 2 show effect of weak percussion over pleurae. 3 and 4 show effect of 
strong percussion over pleurae. 



PEBCUSSION. 83 

The walls of the alveoli, on account of their marked 
distension and the tension, are easily thrown into vibra- 
tion, giving a sound with a characteristic quality, low 
pitched, of great intensity and duration — the normal 
pulmonary sound or resonance. 

( a) Change in Tension. — Increase in tension of the 
pulmonary tissue causes an exaggeration of the normal 
resonance. The two conditions in which this occurs are 
in acute compensatory emphysema of the lung before 
the duration of the distension has allowed of permanent 
dilatation, and in children where there is marked 
elasticity of the alveoli walls and relative overdistension 
of the king. 

The slight change in the tension of the lung that 
occurs at the end of full inspiration and expiration 
causes a slight variation in the resonance. It is most 
marked at the borders of the lung. 

Decrease in the tension of the pulmonary tissue gives 
a tympanitic quality to the sound. The change in ten- 
sion may involve both lungs, and be due to pathological 
changes in the pulmonary tissue, decreasing its elas- 
ticity, as in emphysema. 

The tension of the lung is also lowered by marked 
upward displacement of the diaphragm, as it occurs in 
increased intra-abdominal pressure from ascites, tumors, 
etc. The tension of the lung is also relaxed by any 
accumulation of fluid in the pleural sacs. In old age 
not only is the pulmonary elasticity diminished, with a 
lowering of tension, but the rigidity of the thoracic wall 
causes the percussion note to have a peculiar tympanitic 
quality. 

The changes in tension may be local, as occurs over 
the affected area during the first and third stages of 
croupous pneumonia and in the unaffected portions of 
the lung on the same side during the second stage, due 
to enlargement of affected portion. This is most 
marked when the entire lower lobe is involved. When 
the pleural cavity is sufficiently filled with fluid to 



84 THE RESPIRATORY SYSTEM. 

allow of relaxation of the lung, the same condition 
occurs. The peculiar tympanitic resonance over the 
relaxed portion of the lung in the second stage of pneu- 
monia, and in pleurisy with effusion, has been named 
Skoda's resonance. 

One of the earliest signs of tubercular infiltration of 
a portion of the lung, especially when it affects the apex, 
is the slight tympanitic quality of the percussion note. 

The influence of diminution in the pulmonary tension 
upon the percussion note of the thorax demands further 
consideration. 

In the normal chest, when the blow is struck upon the 
bony thorax, the negative pressure or suction action of 
the lungs causes a movement inward of the ribs, while 
at the same time it prevents a corresponding free out- 
ward rebound. This has the effect of dampening the 
vibrations of the bony thorax. The sound obtained is 
that of the pulmonary tissue, modified to but a slight 
extent by the peculiar sound of the bony thorax. 

With diminished elasticity of the lung and decrease 
in the negative pressure, when the bony thorax is per- 
cussed its movements are not influenced to the same 
degree by the lung, and the percussion note contains a 
larger proportion of the bony quality and pitch ; while 
at the same time the pitch of the pulmonary resonance 
is lower, and the sound obtained is described as slightly 
high pitched, wooden or boardy. 

In percussing the thorax in diseases in which a 
lowering of the tension occurs, the examiner must 
exclude the bony quality of the sound and heightening 
of the pitch that occurs. 

(b) Change in Amount of Pulmonary Tissue. — 
Increase in the amount of pulmonary tissue in any por- 
tion of the lung, whether or not it diminishes the air- 
containing space, produces a change in resonance. 
This change is described as dullness, and is character- 
ized by heightening of the pitch and a peculiar harden- 
ing of the quality, with diminished intensity and 



Pt$(fOB810N. 85 

duration. Tf the size of the air-containing spaces be 
decreased at the same time that the solid structures of 
the lung are increased, the diminution of resonance 
would be in direct proportion to the changes. When 
the tension of the tissue is higher than normal, the pitch 
Will be markedly raised; while, on the other hand, if 
there is marked relaxation, the dullness will be attended 
with a lowering of the pitch and will have a tympanitic 
quality. 

Increase in the tissue of the lung relative to the air- 
containing spaces occurs with fibrosis, where the normal 
structures are increased either as a result of germ infec- 
tion, especially by the tubercle bacilli, or of mechanical 
irritation, as in the conditions classified under pneumo- 
coniosis. 

(c) Changes in the Air-Containing Spaces. — 
Increase in the size of the air-containing spaces and the 
amount of air contained in the lung causes a marked 
augmentation of the resonance produced by percussion, 
and the quality of the sound will depend upon the 
physical condition of the pulmonary tissue. With the 
enlargement of the air spaces, if the tension of the pul- 
monary tissue is increased, as occurs in compensatory 
emphysema and in acute asthma, the pitch is slightly 
raised and the sound is abnormally clear. When, on 
the other hand, the pulmonary tissue is relaxed, as in 
large lung and in the senile form of emphysema, the 
pitch is lowered and of a tympanitic character, giving 
the typical emphysematous or "band-box" percussion 
note. 

When destruction of a portion of the lung tissue 
occurs, forming large air-containing spaces or cavities, 
the percussion sound will depend upon their situation, 
size, form, condition of the walls and the surrounding 
tissue, and whether or not it is open or closed and the 
amount of fluid contained. 

( Vivifies lying close to the surface, and especially at 
the apex, and opening more or less directly into a 



86 THE RE8PIRA TOE Y SYSTEM. 

medium-sized bronchus, give the most marked sound, 
and those the size of a walnut can be detected by per- 
cussion. When situated deeper in the lung, and sur- 
rounded by fairly normal lung tissue, only a faint 
tympanitic quality may be noted. When covered by 
thickened lung tissue, or by thickened pleura, the sound 
becomes dull and at the same time slightly tympanitic. 
This has been variously described as boardy tympanitic, 
dull tympanitic, etc. The influence of the overlying 
tissue may be so great that no cavity sound can be 
obtained. (Fig. 20.) 

When the walls of the cavity are rigid, the pitch of 
the sound changes. In those with lax walls the sound is 
described as cavernous. The quality is tympanitic ; the 
pitch is low, with intensity and duration proportionate. 
In those with tense, rigid walls it is described as 
amphoric, w T ith a more marked resonance and higher 
pitch. These variations in sound are comparative; 
the cavernous merges into the amphoric, and numerous 
subdivisions have been made, as caverno-amphoric, etc. 

When the bronchus leading to a cavity is closed, the 
tympanitic sound is less marked, and the sound is duller 
and high pitched. 

Certain peculiar changes have been detected over 
cavities : 

Wintrich's Change of Sound, or Forcible 
Pitch. — In cavities opening into a large bronchus, and 
situated near the surface of the lung, a change of pitch 
is noted when percussion is made with the mouth open 
or shut. When the mouth is wide open, it is high 
pitched, and more tympanitic than when the mouth is 
closed. Frequently cavities that give no distinguishing 
feature when the mouth is closed are easily detected 
when the mouth is open. 

Gerhardt's Change of Sound. — At times the 
pitch and intensity of the tympanitic sound over a 
cavity changes with the posture of the patient. Various 
explanations have been given of this phenomenon, but 



PERCUSSION. Si 

it is probably due to alterations in size and form of llio 
cavity, its relation to the chest wall and the connecting 
bronchus. The sign is not often detected, but when 
presenl is diagnostic of a cavity. 

Frikdkm en's Respirator? Change of Sound. — 
This is noted when percussion is made during forcible 
inspiration and expiration, and is dependent upon the 
changes that occur in the size of the cavity and the 
tension of its walls. 

The Cracked-Pot Sound. — This is a peculiar 
"clinking" sound heard when forcible percussion is 
made over a cavity connecting directly with bronchus 
during expiration with the mouth open, and is most 
easily obtained when the cavity is situated in the upper 
portion of the lung and the chest walls are flexible. This 
sound can be imitated by loosely clasping the hands 
with palmar surfaces slightly touching and forcibly 
striking the back of one hand on the knee, thus forcing 
the air through the narrow chink formed. This sound, 
while most frequently found in cavity formation, may 
be produced by forcible percussion in the normal lung 
when the thorax is very elastic, as in children. 

Decrease in Size. — As the pulmonary resonance is 
due to the air contained in the lung, diminution in the 
amount will be attended by a corresponding decrease of 
resonance. If the displacement of the air is complete, 
then percussion of that portion of the lung will be 
similar to that obtained over any solid, airless tissue, as 
the thigh or liver, and the sound will be designated as 
flat. 

It is necessary that a clear distinction be made 
between dullness and flatness. As long as any reso- 
nance can be detected, the term dullness must be used 
with some qualifying word denoting its degree. Flat- 
ness means that the sound is absolutely devoid of any 
resonance. 

It is rare for pulmonary consolidation to give a per- 



88 



THE RESPIRATORY SYSTEM. 



fectly flat note, as there is usually enough air in the 

bronchi of the affected portion to give slight resonance. 

Liquid effusions and solid growths in the pleural 



Fig. 19. 




ipaired 



Normal 



Normal 



Dulness y 



Flatness 



Changes in percussion note. 



cavity, on the other hand, are frequently large enough 
to give a perfectly flat sound. 



PERCUSSION. 



SO 



The percussion note obtained when the lung has been 
rendered more or less airless or solid depends upon the 
Beat of the consolidation. Jf the consolidated area is 



Fig. 20. 



Deep Seated Consolidation 

masked by — —-& 
Emphysematous Lung 




Localized Emphysema 

Compensatory 

to 

Consolidation 

(Dulness) 



Dalness with 
Tympanitic quality 



close to the surface, immediately underneath the pleura, 
its influence upon the resonance would be marked, and 



00 THE EESPIBA TOR V SYSTEM. 

it can be best detected by lighl rather than by heavy 

percussion. If, on the other hand, it is situated deeper 
in the lung, and separated from the pleura and bony 
thorax by a zone of air-containing lung, then, in direct 
proportion to its depth, will it influence the resonance 
obtained, and more forcible percussion is needed. This 
can be best understood by referring to Figs. 19 and 20. 

(5) Influence of Heart and Liver. — The resonance 
of the lung is impaired by the solid structures (heart 
and liver) that are covered to a greater or less extent 
by pulmonary tissue. The extent and degree of the 
dullness will depend upon the size and mobility of the 
lung on the one hand and that of the solid organs on the 
other. 

The dullness that is detected over these organs, which 
gradually increases in degree until it merges into the 
perfectly flat sound of the organ itself, is known as rela- 
tive cardiac and liver dullness. The influence of these 
organs upon the resonance and force of the blow neces- 
sary to elicit this relative dullness is indicated by Figs. 
21 and 22. 

The normal boundaries of these areas and the diag- 
nostic significance of changes in extent are discussed 
Parts III and IV. 



INDIVIDUAL AND REGIONAL VARIATIONS OF 
PERCUSSION SOUND. 

From what has been said about influence of the dif- 
ferent structures upon the percussion note, it is readily 
appreciated that no standard can be set. Each 
patient will have an individual variation within the 
range of normal, as the soft parts are thick or thin, the 
bony thorax flexible or rigid, the lungs large or small, 
with high or low tension, and, in addition, the sound 
will vary according to the portion of the thorax per- 
cussed. 

As the value of percussion lies in the comparison of 



PERCUSSION. 



01 



the note obtained over corresponding spots on the two 
sides, it is necessary to keep in mind the normal varia- 
tions that occur over these spots. 

The percussion note over the right lung, from the 
apex to the second interspace in the axillary line, is 
slightly higher in pitch, and duller than on the left side. 
This is due to the bronchi on the right side being rela- 

Fm. 21. 




Absolute and relative heart and liver dullness, also regional variation 
in thorax. 



tively larger and nearer the surface. The change in 
percussion corresponds to the increase in vocal fremitus 
over the same area. 

The percussion note on the right side from the fourth 
interspace is modified by the relative liver dullness, 
while on the left side, beginning at the third interspace, 
close to the sternum, and corresponding to the site of 



92 



THE RESPIRATORY SYSTEM. 



the heart, the cardiac flatness and relative dullness is 
present. These variations are noted in Fig. 21. 



PERCUSSION OUTLINES OF THE LUNG. 

Percussion gives valuable information concerning the 
size and mobility of the lung, and no examination is 
complete unless the percussion outline of the borders of 

Fro. 22. 




Percussion outline of the lung 1 (anterior; . 



the lung during inspiration and expiration is deter- 
mined. 

The only boundaries or borders that can be definitely 
mapped out by percussion are a superior and inferior, 
and that portion of the anterior that is uncovered by the 
sternum and overlies the heart. At the end of quiet 



nK/KTSSION. 



93 



inspiration the superior border of the Lung reaches two 
or throe centimeters above the clavicle, occupying the 
supraclavicular space. 

With full inspiration, the superior border is carried 
a finger to a finger and a half higher, and the space is 
filled out in all directions; while the percussion note is 
clearer and fuller from the increased tension of the 

Fig. 23. 




Percussion outline of the lung (posterior). 



pulmonary tissue and enlargement of the air spaces. 
The superior border does not rise as high when there is 
pleuritic thickening and adhesions. In emphysema the 
superior border is higher than normal with expiration, 
but there is not a corresponding increase in size during 
inspiration, and the note has a tympanitic quality, with 
but slight change at the end of full inspiration. The 



94: THE BESPIB. I TOBY SYSTEM. 

inferior borders on tlie two sides are slightly different. 
On the right side, starting from the base of the xiphoid 
cartilage, it curves obliquely downward and outward 
across the sixth rib in the axillary line, the tenth rib in 
the scapular line, and meets the vertebral column at the 
junction of the eleventh rib. 

On the left side, the inferior border can only be 
determined in the axillary line, as the presence of the 
stomach renders its detection in the mammary line 
difficult. (Figs. 22 and 23.) 

AUSCULTATORY PERCUSSION ( Stethoscopic Percussion) 

In this method the chest piece of the stethoscope is 
placed upon the chest over the organ that is under 
examination ; mediate and immediate percussion is 
made from a distance toward the point wh^re the stetho- 
scope rests, and the variations in the sound are noted. 
When the percussion is made directly over the organ, a 
marked increase in the intensity of the vibrations is 
both heard and felt. 

Within certain limitations, it is a valuable method of 
examination, allowing of a differentiation between con- 
ditions giving the same sound, as between the flatness of 
the heart and liver where the two organs are contiguous ; 
between right-side pleurisy with effusion, pulmonary 
consolidation- and liver flatness. 

In order to be of use, the chest piece of the stethoscope 
should be small and rest wholly over the organ under 
examination. A special part to replace the ordinary 
chest piece should be used, so as to allow of its being 
placed between the ribs, thus avoiding the vibrations 
readily conveyed by the bony thorax. The percussion 
should be light, and, as the value is comparative, the 
points percussed should be equally distant from the tip 
of the stethoscope. 

Another method which I have found very sensitive, 
and which avoids the vibrations of the bony thorax, is 



PEBCUSSIOM 



to listen to the percussion note with the chest piece of 
the Btethoscope not touching the surface, but held just 
above and close to the point of percussion. In mapping 



Fro. 




Auscultatory percussion. 



out the relative dullness of the heart and liver, it is 
more definite than when chest piece rests on the bony 
thorax. (Fig. 24.) 



CHAP TEE V. 

AUSCULTATION. 

Auscultation of the lungs is the act of listening at 
the surface for the sounds made within the thorax dur- 
ing the act of breathing, and may be performed in two 
ways: Immediate, in which the ear is placed directly 
upon the chest which is protected by a thin covering. 
Mediate, in which one of the different forms of stetho- 
scope is used. 

Each method has its advocates, and both are useful. 
The advantages of immediate auscultation are that (a) 
there are no modifications of sound occurring through 
the use of instruments ; (b) the ear appreciates better 
the slight changes in the normal elements of the sound ; 
(c) the ear notes the movements of the thorax, which 
occur at the time the sound is heard; (d) there is less 
exposure of the surface. 

The advantages of the use of the stethoscope, or 
mediate auscultation, are : (a) It is easier to examine 
certain portions of the chest more or less inaccessible to 
the ear, as the supraclavicular fossa; (b) it limits the 
sphere of examination to the small area covered by the 
chest piece of the stethoscope ; (c) delicacy often dic- 
tates its use over certain portions of the body, as the 
breasts ; (d) the examiner avoids infection and contami- 
nation by parasites. 

The disadvantages are that certain elements of sound 
are modified or distorted by the resonance of the instru- 
ment used, and many extraneous sounds are also intro- 
duced, as rubbing or scratching frictions sounds made 
by the rubbing of the stethoscope on the surface, and 
muscle sounds or ci'eakings are intensified. Children 



AUSCULTATION. ^ 

are often frightened by use of an instrument. Where 
a person is very thin, it is impossible to have the stetho- 
scope tit closely to the surface, and so to exclude the 

sounds present in the room. 

Students should he thoroughly familiar with the 
sounds obtained by the direct method, and should use 
the indirect for certain special purposes only. 

To auscultate satisfactorily, attention should be given 
to the position of the patient. Both sides of the chest 
should have opportunity to move with equal freedom. 
The patient should breathe naturally, and care should be 
taken that inspiration and expiration are not noisy. It 
is impossible for many persons to breathe naturally 
when their attention is called to the act. Usually the 
inspiration is taken quickly and forcibly; the breath is 
held for an appreciable time, and then either forced out 
rapidly or allowed to escape so slowly that no sound is 
heard. In nervous patients fairly natural breathing 
may be obtained after coughing, or by having the patient 
first talk for a certain time. All constricting clothing, 
as stays, etc., should be removed, so that the chest may 
be as nearly normal as possible. As the value of 
auscultation is comparative, symmetrical points on the 
two sides should be examined and the differences noted. 

PHYSIOLOGY OF NORMAL BREATH SOUNDS. 

It is necessary to have a clear understanding of the 
manner in which the normal respiratory murmurs, or 
breath sounds, are produced in order to appreciate and 
correctly interpret the variations that are heard over the 
different portions of the lung in health and the altera- 
tions that occur in disease. 

A- the name implies, the breath sounds depend upon 
the respiratory movement, and necessarily occur only 
during inspiration and expiration. The modifications 
of these sounds heard over the different portions of the 
chest may be divided into two groups: 

7 



98 THE RESPIE. I TOE V SYSTEM. 

(A) Those which depend upon the variations in the 
normal sounds. These variations are limited to (a) 
quality or character, (b) intensity, (c) pitch, (d) dura- 
tion, (e) rhythm, (f) the relative length of expiration 

and inspiration to each other. 

(B) To the production of new or adventitious sounds 
or rales, which may be dry or moist, friction, etc. See 
page 112. 

During inspiration enlargement of the thoracic cavity 
occurs in all directions, causing (a) movement of air in 
the respiratory tract; (b) change in the tension of the 
tissues forming the walls of the bronchi, bronchioles and 
alveoli. 

In quiet breathing 30 cubic inches of tidal air are 
drawn into the respiratory tract during inspiration and 
forced out during expiration, and, as the estimated 
capacity of the larynx, trachea and bronchi is 10 cubic 
inches, and that of the alveoli after quiet expiration is 
150 cubic inches, it is evident that the tidal air is car- 
ried even into the alveoli, and that there is aerial move- 
ment throughout the entire respiratory tract. Passing 
to and fro through the glottis, the tidal air is thrown 
into vibrations that are intense enough to be audible. 

Laryngeal Breath Sounds. — The sound produced at the 
glottis is known as the laryngeal breath sound, and has 
the following characteristics: It is heard with both 
inspiration and expiration, but with a distinct break or 
pause between them, as the inspiratory sound is not 
audible during the latter part of the act. 

The sounds produced during inspiration and expira- 
tion are nearly equal in length, that of expiration being 
slightly longer. The sound is harsh and blowing, the 
quality being tubular ; the pitch is high, that of expira- 
tion being harsher and higher pitched than that of 
inspiration. 

When the mouth is closed and the breathing is 
through the nose, the sound produced is more intense, 



AUSCULTATION. 09 

harsher and higher pitched, as the vibrations made at 
the glottis are reinforced by those produced in the 
pharynx. The laryngeal sound may be imitated by 
placing the tongue in the position to pronounce "h" or 
"ch" and breathing deeply and regularly. 

The intensity and character of the laryngeal sounds 
depend (a) upon the force and rapidity with which the 
tidal air rushes through the glottis; (b) the size of the 
glottis ; (c) the position of the vocal cords ; (d) the con- 
dition of the tissues of the larynx. Thus the sounds 
vary to a certain extent in each individual. As the 
vibrations made at the glottis are the basis of all sounds 
normally heard over the lung, the laryngeal breath 
sounds serve as a standard in each case by which an 
estimate of what should be the normal intensity of the 
respiratory sounds heard over the other portions of the 
chest. 

The vibrations made at the glottis are conducted 
through the respiratory tract simultaneously by two 
channels: (1) Aerial, i. e., vibrations of columns of 
air contained in the bronchi, bronchioles and alveoli ; 
(2) the tissues of the walls of the bronchi, bronchioles 
and alveoli. 

Aerial Conduction. — The laryngeal sound is conducted 
by the aerial vibrations through the trachea to its bifur- 
cation into the primary bronchi almost unchanged, 
except for a slight toning down of the harshness. The 
laryngeal, or tracheal, sound represents the highest type 
of tubular or bronchial breathing, and is normally heard 
over the larynx and trachea; at times over the upper 
portion of the sternum in front and over the vertebral 
column as far as the fifth dorsal vertebra behind. It 
is heard over other regions of the chest only when patho- 
logical changes have occurred in the respiratory tract, 
that permit its conduction from its normal site to other 
areas. 

At the bifurcation of the trachea, the column of mov- 
ing and vibrating air is divided into two uneven parts, 

L.ofC. 



100 THE RESPIR. I TORY SYSTEM. 

the larger passing to the right bronchus, the smaller to 
the left. With this division certain changes occur, 
which influence the aerial vibrations that have been 
carried down from above. 

(1) The united capacity of the two bronchi being 
greater than that of the trachea, the force of the current 
of tidal air is less. 

(2) Reflection, or reverberation of the laryngeal 
vibration, which causes confusion of the sound. 

(3) The impinging of the column of air on the angle 
of bifurcation adds new vibrations and a new quality 
of sound to that received from above. 

Tissue Conduction. — The vibrations transmitted 
through the walls of the trachea and bronchi convey the 
laryngeal sound unchanged in quality, and but slightly 
weakened. 

The effect of these two series of vibrations is to so 
modify the sound in the primary bronchi that it can be 
distinguished as a type, i. e., bronchial breathing. 

Bronchial breathing differs from the laryngeal sound 
as follows : The tubular quality is slightly diminished, 
and is less sharp, the change being most marked on 
inspiration. The pitch is not as high, and there is a 
corresponding loss in intensity and harshness. Inspira- 
tion and expiration are nearly equal in duration, 
expiration alone being slightly shortened, and the pause, 
while present, is not so marked. 

As the tidal air descends along the bronchial tract, at 
each division of the column similar changes occur, as 
at the bifurcation of the trachea. 

The Modifications of the Aekial Vibrations that 
occur in the different divisions of the bronchi are as 
follows: (1) The increased capacity of the branching 
tubes (a) reduces the force of the current in the tidal 
air and (b) causes diffusion of the vibration. These 
two factors lead to a loss of intensity in the sound 
produced. 

(2) The refraction or reverberation occurring in the 



AUSCULTATION. 101 

bronchi causes the tubular laryngeal sound to become 
confused in character, the harsher tones being especially 
modified, while the more musical elements persist. 
This makes tin 4 pilch of the sound lower than that 
which is heard above the large bronchi and larynx. 

Obliteration or change in the harsher qualities has 
been variously explained, but the mere fact of their 
loudness or harshness causes their reverberation to occur 
more easily, and therefore the primary vibrations are 
interfered with by the secondary vibrations of reverbera- 
tion. 

(3) At each bifurcation of the bronchi the moving 
column of tidal air has sufficient force to set up new 
vibrations, which., being added to those received from 
above, modify the quality of the sounds ; and although 
the sound remains tubular, it has a softer blowing 
character. 

The Modifications of Vibrations through Tis- 
sue Conduction. — The walls of the large and medium- 
sized and cartilaginous bronchi are good conductors of 
vibration. The change that occurs as the vibrations 
are carried through the tissues of the different branches 
of the bronchial tree is chiefly loss of intensity, but the 
bronchial character persists. On account of the rigidity 
of the bronchi, tissue vibrations are influenced but 
slightly by the aerial vibrations within them. 

As a result of these two classes of vibrations, aerial 
and tissue, the sounds heard over all portions of the 
bronchial tract will be more or less characteristic. The 
pause betw r een the inspiratory and expiratory sounds in 
the larynx is w r ell marked. This pause becomes less 
and less marked the farther down the respiratory tract 
the examination is made. This is due to the more 
continuous movement of air during inspiration and 
expiration in the lower divisions of the bronchi. Above 
there is merely the tidal air going in and out; below 
there is the more continuous movement of not only the 
tidal air, but also the columns of residual air. During 



102 THE RES PIE A TORY SYSTEM. 

the latter portion of inspiration the air passes through 
the glottis without setting up audible vibrations, while, 
on the other hand, on account of the position of the 
vocal cords during expiration, audible vibrations are 
produced throughout the entire act. Lower down in 
the bronchi the added vibrations cause a continuous 
sound, increasing in intensity, to be made throughout 
inspiration. While, on the other hand, in expiration 
the current becomes progressively feebler. 

In the larynx and large bronchi the tubular quality 
of the sound is equal during inspiration and expiration. 
Over each successive lower division of the bronchi the 
inspiratory sounds lose their pure bronchial character, 
while the expiratory sound retains it to a greater degree. 
This difference in the amount of tubular element is due 
to the fact that in inspiration new vibrations are added 
at each division of the bronchi, which modify the 
tubular quality. During expiration, on the other hand, 
no new sounds are added. 

If it were possible to apply the ear or the stethoscope 
to the different subdivisions of the bronchial tree, each 
would give its own peculiar type, having a characteristic 
quality, pitch, intensity and duration. (Fig. 25.) 

Certain pathological conditions allow these varying 
degrees of bronchial breathing to be heard at the sur- 
face, and according to the character of the sound heard 
the nature and extent of the anatomical changes in the 
lung are determined. 

Changes in the Bronchioles and Aeveoei. — 
From what has already been said of conduction of the 
glottic vibrations by the air contained in the trachea and 
bronchi, and by the walls of the tubes, and the modifica- 
tions that occur in the sound in different portions of the 
bronchial tract, it is easy to understand that still greater 
modifications will take place in the bronchioles and 
alveoli. As long as the divisions of the bronchial tubes 
contain cartilage and muscular tissue, the vibrations 
transmitted through the homogeneous tissue preserve in 



AUSCULTATION, 103 

a large measure the tubular quality of the laryngeal 
sound, and are not easily modified by the aerial vibra- 
tions. 

"Below the diameter of 1-24 inch (1 mm.) the bron- 
chial tubes have neither cartilages, mucous glands nor 
any continuous muscular coat; circular and longitudinal 
elastic fibres replace the muscular coat." (Powell.) 

This change in the structure of the bronchi has a 
marked influence on the conduction of the laryngeal 
sounds onward towards the surface, which has been so 
marked a feature of the vibrations transmitted by the 
tissues. As the structure of the bronchioles and alveoli 
becomes less and less homogeneous with that of the 
larger bronchi, the vibrations received from above are 
not conveyed so easily. The loss of the tissue vibration 
causes a dampening of the tubular or bronchial quality 
of the sound. As the structures of the bronchial tubes 
and alveoli becomes more membranous and tense, they 
are influenced to a greater degree by the aerial vibra- 
tions. 

The rapid breaking up of the smaller bronchi into 
bronchioles causes a still more marked change in the 
aerial vibrations received from above. They are dif- 
fused, reflected again and again ; the sound is confused ; 
the harsh tubular and blowing character is lost; the 
softer, more continuous and rustling (musical) quality 
alone remaining. 

There has been much discussion whether the move- 
ment of the tidal air in the bronchioles and its passage 
into the alveoli is sufficient to produce audible vibra- 
tions, and whether the sound heard at the surface of the 
lung during inspiration is due entirely to the vibrations 
made at the glottis, changed by transmission through the 
lung, or is in part composed of vibrations made at the 
junction of the bronchioles with their infundibuli. 
Some claim that the sound heard at the surface during 
inspiration is made in the alveoli. 

After quiet expiration, the capacity of the alveoli is 



104 THE RESPIB. I TOR Y SYSTEM. 

estimated at 150 cubic inches; the amount of tidal 
air in quiet breathing is 30 cubic inches, which in forced 
inspiration and expiration may reach 200 cubic inches 
in man and 150 cubic inches in the female. There is 
no question that it is possible for the tidal air to pass 
from the narrow bronchioles into their relatively wide 
infundibuli, and to produce vibrations which, if not 
audible in themselves, would intensify in some respects 
and modify in others the vibrations, already present, 
which had their origin at the glottis. 

The aerial vibrations, and especially those in the 
alveoli, play an important part in the production of 
the inspiratory sound heard at the surface. They 
explain why the vesicular element is present to a greater 
or less extent as long as tidal air reaches the alveoli, 
even though changes in the stroma of the lung may 
allow bronchial sound to be heard through tissue con- 
duction, and why inspiration does not have as tubular a 
quality as expiration. In inspiration through the 
enlargement of the thoracic cavity the tissues of the 
alveoli and bronchioles are rendered more tense, have 
greater powder of conduction, and are more easily thrown 
into vibrations, so that there is a corresponding increase 
in the intensity of the sound up to the end of the act. 

Normal Respiratory Murmur. 

Over the surface of the lung the breath sounds (the 
respiratory murmur) have the following characteristics 
or elements during inspiration : 

The quality is variously described as breezy, rustling, 
sighing, slightly shuffling or vesicular, corresponding to 
the sound produced by regular and natural breathing 
when the lips are placed in a position to pronounce "F" 
or "V." The pitch is low; the intensity increases to the 
end, and is heard throughout the act (duration). The 
rhythm is regular. The sounds of inspiration and 
expiration occur at regular intervals. 



AUSCULTATION. 105 

All these elements of the respiratory murmur will 
vary normally within wide limits in different indi- 
viduals, but will always have a definite relation to the 
intensity of the sounds heard over the larynx and 
trachea, as has already been noted. 

The expiratory portion of the respiratory murmur 
immediately follows that of inspiration, and differs in 
the following respects: The quality is harder, the 
breezy vesicular (dement being replaced by a slight 
blowing sound; the pitch is higher; 1 the intensity is 
less, being loudest at the beginning and rapidly fading- 
out, so that its duration is only one-half to one-third 
that of inspiration. 

- It is necessary to explain why these differences occur 
in expiration in order to understand the occurrence of 
1 m thologica 1 cha nges. 

It has already been noted that inspiration is a 
muscular act which continues until the thorax is fully 
expanded. The laryngeal sound is made at the glottis, 
and is conducted downwards by (1) the current of tidal 
air which is towards the surface of the chest, and (2) 
by the tissues in the bronchi, bronchioles and alyeoli, the 
tension of which increases to the end of the act. In 
addition to the vibrations made at the glottis, other 
vibrations are added at different parts of the tract, and 
especially at the opening of the bronchioles into their 
infundibuli. All of these factors cause the inspiratory 
part of the murmur to have its peculiar quality and 
pitch ; to increase in intensity to the end, and to be heard 
throughout the act. 

Expiration, on the other hand, is normally a passive 
act, which depends upon the elasticity of the thorax and 
the pulmonary tissue and the contraction of the muscle 
fibres present in the bronchi. This force is greatest at 
the beginning. The sound in the larynx is made at the 
level of the vocal cords, and the direction of the tidal air 

1 Many authors state that the pitch of expiration is lower than that of 
inspiration. 



106 THE RESPIB. ! TOE Y SYSTEM. 

is upwards and away from tlic surface of the chest. 
The direction of the expiratory current of air inter- 
feres with aerial conduction of the sound downwards. 
As the tidal air is forced out of the alveoli into the 
tubes, no new vibrations are made in the bronchioles or 
tubes. 

The sound that is heard at the surface in expiration 
is chiefly that conveyed by the tissues of the respiratory 
tract, so that the quality lacks the vesicular element and 
is somewhat blowing and hard, and its pitch is higher 
than inspiration sound. As the tidal air is forced out 
of the lung the tension becomes less, losing the power to 
conduct, so that the intensity is most marked at the 
beginning, rapidly diminishing ; and the sound is heard 
only during a short part of the time, or may be entirely 
wanting, especially where the expiratory laryngeal 
sound is naturally very soft or the expiratory force 
weak. 

The fact that during expiration the vibrations are 
chiefly conducted by the tissues explains the tendency 
of the blowing or bronchial element to be so much more 
pronounced during this portion of the murmur. 

Regional Variations of the Breath Sounds. — 
The breath sounds vary in intensity, duration, quality, 
pitch and in the relative lengths of the sounds heard 
during inspiration and expiration over different por- 
tions of the lung. 

It is necessary to have a thorough knowledge of the 
normal variations in order to recognize the alterations 
that occur in morbid conditions, because a type of 
breathing that is normal for one region would be patho- 
logical if heard in another. 

It has already been shown that over the larynx, 
trachea and primary bronchi the tubular sound is heard 
unmodified, and constitutes the laryngeal, tracheal and 
bronchial types of breathing. 

Over the interscapular space, opposite the spine of the 
scapula, the sound is neither pure bronchial nor entirely 



AUSCULTATION. 107 

vesicular in quality and pitch, but is of an inter- 
mediate character. The tubular sound is modified, so 
that inspiration lias a soft, blowing, but somewhat bron- 
chial, character, and the pitch is not as high as over the 
trachea. The expiratory sound is separated from the 
inspiratory by a shorter pause, and corresponds to the 
inspiration sound in quality and pitch, but its duration 
is not as long as over the trachea. The tubular element 
is more marked on right side than the left, on account of 
the relation of the trachea and bronchi to spine and ribs. 
(Plate II.) 

In front of the chest on the right side, at the junction 
of the second rib with its costal cartilage, the respiratory 
murmur differs from that heard on the left side in the 
corresponding region. While vesicular in character, 
there is a slight blowing element added, and its intensity 
and pitch are slightly raised. Over the right apex of 
the lung the same difference is present in a more limited 
degree, due to the origin of the bronchus supplying the 
upper lobe of the right lung. 

The reason for the normal regional differences of 
vesicular murmur is the relative nearness of the large 
bronchi to the chest wall, so that, although these are 
covered by lung tissue, the elements of the bronchial 
sound are present in the respiratory murmur in a 
greater degree than elesewhere. 

Types of Respiratory Sound. — Various classifications 
have been made of the different types of breath sounds 
heard in health and in disease. 

Some authors use as a basis of their nomenclature the 
diseases of which the sounds are diagnostic; others 
employ terms descriptive of the pathological changes. 
The one that is most commonly used, and also the most 
satisfactory, is that which considers the elements of the 
sounds and groups the types according to the changes 
that occur in intensity, rhythm, duration, quality, pitch 
and the relative length of inspiratory to the expiratory 
sound. 



108 THE BESPJE. 1 TOR V SYSTEM. 

('manges in Intensity. (1) Increased, Exagger- 
ated, ( Compensatory, Vicarious, Puerile Breathing. — 
The chief change from the normal is in the intensity of 
the breath sounds. [nspiration has the vesicular ele- 
ment accentuated. Expiration is slightly longer than 
normal, and of a soft, blowing character. It occurs 
whenever the breathing is very deep and active, as in 
forced voluntary breathing; also in dyspnoea and over 
portions of the lung, which by increased activity are 
compensating for imperfect action in another part. 

Puerile breathing, which is the normal breathing of 
children under twelve years of age, differs from exag- 
gerated breathing, in that both inspiration and expira- 
tion are abnormally loud and sharp, and expiration is 
nearly as intense and long as inspiration. It is some- 
what blowing in character, and may have a slight 
bronchial quality. 

(2) Diminished, Feeble, Senile, Emphysematous 
Breathing. — The sounds are faint, and heard only for a 
short time, and expiration may be inaudible. The 
diminished intensity may be due to shallow breathing, 
imperfect muscular action caused by weakness, pain in 
the muscles, nerves or pleura ; rigidity of the bony 
thorax; thickness of the soft parts of the thorax and 
thickenings of, or exudations and effusions into, the 
pleural sac; interference with the movement of air 
through the bronchi ; weak glottic sound, dependent 
upon normal or pathological conditions of the larynx. 

The breath sounds that occur when the elasticity of 
the lung is impaired, as in emphysema and old age, 
differ from simple diminished breath sounds, in that 
the inspiratory is short and weak, and the expiratory 
sound is relatively stronger and longer. 

(S) Absent or Suppressed Breathing. — The breath 
sounds are not heard. This is due to changes that - 
render conduction to the surface impossible. It is most 
marked in effusions of serum, pus or blood into the 
pleural sacs; in closed pneumo-thorax with pulmonary 



AUSCULTATION, 100 

collapse; over cavities filled with fluid; with occluded 
bronchus, and occasionally when there is great thick- 
ness of the chest wall associated with feeble breathing. 

A i/n.RATioNs in Rhythm. — Interrupted, jerky, 
wavy, cog-wheel breathing. Instead of the inspiratory 
breath sound being' even and continuous, with a gradual 
increase in intensity, it is broken and puffy. The 
expiratory sound may also be uneven. 

This may be due to irregular muscular action, as in 
nervous patients and in painful conditions of the thorax 
and pleura, or to interference with the passage of air 
tl) rough the bronchi, as occurs in early tubercular 
infiltration of the apices, "when the air enters different 
lobules at different times." 

Over the heart and large blood-vessels a peculiar, 
jerky, puffing sound may be heard, due to the cardiac 
systole forcing from the alveoli. 

Alterations iint Duration. — The significance of 
change in duration of breath sounds depends upon (a) 
whether the normal relation is preserved between the 
sounds of inspiration and expiration ; (b) whether it is 
associated with adventitious sounds, and (c) whether 
there is any alteration in pitch and quality. 

The inspiratory and expiratory sounds, while preserv- 
ing their normal relations, may be lengthened or short- 
ened by all conditions which have been mentioned as 
producing increased or diminished breath sounds. 

Prolonged Expiratory Breath Sound. — This occurs 
under various conditions. 

(1) When the expiratory sound is prolonged, but is 
low pitched and faintly blowing in quality, it depends 
upon diminished elasticity of the lungs, and is asso- 
ciated with decrease in the length of inspiratory sound, 
witli a slight pause between inspiration and expiration. 
Loss of elasticity occurs in old age and in emphysema. 
Tin's type of breathing has therefore been designated as 
"emphysematous." 

(2) The expiratory sound may be prolonged, and 



110 



THE RESPIRATORY SYSTEM. 



Fig. 25. 




AUSCULTATION. Ill 

accompanied by moist or dry rales, duo to narrowing 
of the tubes by secretion or by spasm of the muscular 
tissue, as occurs in asthma, bronchitis and the early 
stage of pulmonary tuberculosis. 

(3) A prolonged expiratory sound may be associated 
with a higher pitch and a blowing quality, due to 
changes in the lung which increase its power of con- 
ducting to the surface the sound which is normally 
present in the bronchi throughout the entire expiratory 
act. This may be due to increase in or induration of 
the normal structure of the lung, as in the early stages 
of tubercular infiltration, interstitial pneumonia or 
fibroid thickening. 

This type of breathing is normally present over the 
apex of the right lung. 

A prolonged expiration sound, associated with slight 
increase of the tubular quality and heightening of the 
pitch, marks the faintest alteration in the elements of 
the respiratory sounds in the transition from the normal 
vesicular murmur to the different degrees of bronchial 
breathing. 

x\lterations in Quality and Pitch. — The changes 
that occur in the quality or character of the breath 
sounds depend upon the addition of the bronchial and 
tubular and decrease of the vesicular elements. The 
extent to which this may occur varies. Based on the 
proportion of the vesicular and bronchial quality 
present, various subdivisions of bronchial breathing 
have been made : 

(1) Broncho-vesicular, indeterminate, subtubular, 
hinted or indistinct bronchial breathing. Sharp breath- 
ing with bronchial quality in expiration; transition 
breathing ; rude respiration ; harsh breathing. 

As the names indicate, the distinguishing feature of 
this type is the presence of both vesicular and bronchial 
quality. This depends upon the changes in the lung, 
which allow the bronchial sound to be heard at the sur- 
face. These changes may be due to tubercular infiltra- 



112 THE EE8PIEA TOR V SYSTEM. 

tion, croupous pneumonia, or fibroid induration from 
any cause. It is normally j^resent in the interscapular 
region. 

The term "broncho-vesicular" is by some extended to 
all cases of bronchial breathing which do not have the 
well-marked tracheal quality, while others limit it to 
that type where a faint bronchial quality is added to 
the vesicular breathing. 

The terms "rude" and "harsh" have been used by 
some authors to describe certain grades of broncho- 
vesicular breathing, but should be discarded, as they 
are misleading, having been employed by others as 
synonyms for exaggerated breathing. 

(2) Pure bronchial breathing is characterized by 
absence of the vesicular quality. Both the inspiratory 
and expiratory sound are high pitched and tubular; 
that of expiration the more markedly so. 

(8) High-pitched, blowing, tubular and tracheal 
breath sounds merely have reference to the intensity and 
extent of the bronchial elements. 

(1+) Cavernous and amphoric breathing are modifi- 
cations of the bronchial type. The former is low 
pitched and hollow; the latter is high pitched and 
metallic. 



(B) ADVENTITIOUS SOUNDS. 

In addition to the breath sounds present in the chest, 
there may be heard certain abnormal or adventitious 
sounds, which depend entirely upon pathological 
changes in the bronchi, alveoli and pleura. 

Adventitious sounds are divided into three classes : 



Dry Rales, Moist Rales and Friction Sounds. 

(1) Dry Rales, or rhonchi, are musical sounds, pro- 
duced by vibrations set up in those bronchial tubes 
whose lumen has been markedly narrowed by tenacious 



AUSCULTATION, 



113 



exudates, contraction of the muscular coals or pressure 
oi tumors. These changes arc of such a nature as to 
practically convert the bronchial tubes into wind instru- 
ments. 

Fig. 26. 



— 




These sounds or rales may vary in quality, pitch, 
intensity and duration, according to the size of the 
tubes involved. 



114 THE EE8PIBA TOR )' SYSTEM. 

They are usually divided into two classes, sonorous 
and sibilant. 

Sonorous bales arc snoring, low-pitched,, loud 
sounds, which may be heard during both inspiration and 
expiration, or may be limited to one part only of the 
respiratory act, according to the nature of the cause. 
They may be heard in connection with the vesicular 
murmur, or may entirely obliterate it. 

Stridor is a tvpe of sonorous rale in which the vibra- 
tions are very coarse, and the sound produced hoarse 
and low pitched. It occurs in diseases of the larynx, 
trachea and main bronchi. The vibrations producing 
stridor and sonorous rales may be strong enough to 
produce tactile fremitus, as described in palpation. 

When the narrowing in the trachea and large bronchi 
is not sufficient to produce a musical sound, but is still 
sufficient to increase the tubular quality normally 
present, it will influence the respiratory murmur by 
adding a bronchial element, as will be described later. 

Sibilant rales are whistling, piping, squeaking, 
humming, hissing sounds, which are markedly musical, 
shrill and high pitched. The quality and the pitch will 
depend upon the size of the tube, the degree of contrac- 
tion, the force of the current of air, the conditions of the 
pulmonary tissue and the conduction of the sound to 
the surface. 

These rales are permanent or transient, according to 
the nature of the cause. When the narrowing of the 
tube is due to pressure of a tumor or to a growth within 
the bronchus, the rales will be permanent. When, on 
the other hand, the sound is caused by secretions in the 
tubes or spasm of the muscular fibers, they are variable 
and inconstant, disappearing from one spot and appear- 
ing in another. 

They also change in character. At one time they 
may be hissing, shrill or whistling, and again sonorous, 
as tubes of a different size are involved. Coughing, 
deep inspiration or the inhalation of chloroform or ether 



AU8GULTATI0N. ll< r > 

will modify those of a transient nature, according to 
the cause. 

While usually there is little difficulty in determining 

what rales belong to the dry type, in the finer, less 
musical sibilant ones it is often a matter of opinion how 
they are to be classified. 

(2) Small, Medium and Large Moist Rales. — Moist 
kales, as the name indicates, are due to the vibrations 
produced by the movement of air through fluid (mucus, 
serum, blood or pus) in the air-containing spaces of the 
lung. 

Certain characteristics of the rales depend upon the 
nature of the fluid. When it is thin and watery, the 
rales will have a moist, bubbling sound; when it is 
thick, in addition to the moist sound, there will be an 
element of sharpness or stickiness, as the bubbles burst 
with an explosive noise. 

The quality and pitch of moist rales are modified by 
the condition of the surrounding lung. When the lung 
is normal, the sound of the rale loses its sharpness in 
transmission, the moist character only remaining. But 
in consolidated areas the rale has a certain ringing 
character, due to the supposed resonating effect of the 
consolidated structures and their increased conducting 
power. 

The variations that occur in the characters of moist 
rales have led writers and teachers to adopt various 
classifications and to designate their subdivisions by 
names which they considered more or less descriptive 
of the sound, or of the pathological condition that ren- 
dered their occurrence possible. 

Unfortunately, different authors do not use the same 
descriptive terms in the same sense, so the "crepitant" 
rale includes not only the finest crackling sound, but 
also those of larger size, which are by others classified 
as "subcrepitant," or "small mucus." 

This want of agreement in classification and nomen- 
clature has led to great confusion, and it is particularly 



116 THE RESPIRATOR V SYSTEM. 

perplexing to the student, as it conveys the impression 
that there is a diversity of opinion as to the diagnostic 
significance of these adventitious sounds. 

It is almost hopeless to arrange a classification that 
will include all the terms used. 

Fortunately, the tendency is more and more to avoid 
a specific descriptive term, and to describe the sound in 
terms of quality, pitch, duration and intensity. 

Crepitations, or "Crepitant Rales." — These are 
the minutest of the moist rales, and have been by some 
writers described as belonging to the dry type. They 
have a fine, somewhat dry, crackling sound, similar to 
that produced by slowly and firmly rubbing a lock of 
hair between the finger and thumb close to the ear. At 
times they have a sharpness that resembles the sounds 
produced by the crackling of salt thrown upon the fire, 
or the sound gives an impression of stickiness, as when 
the moistened thumb and finger, having been pressed 
together, are separated close to the ear. 

Their pitch is high, and they convey the impression 
of being produced near the surface. They occur in 
showers or explosions, and are of uniform size. 

They are persistent at the spot first heard, not being 
removed by coughing; and are usually restricted to 
inspiration, although they may at times be heard 
momentarily just at the beginning of expiration. Some 
authors state that they may be heard only during expira- 
tion. Formerly it was claimed that one of the dis- 
tinguishing features of the crepitant rale was that it 
occurred only during inspiration, and that any rale 
having the same general characteristics, but occurring 
during expiration, could not be a crepitant rale. 

There are differences of opinion as to the place and 
mode of production and diagnostic significance of the 
crepitant rale. Some claim that they are intrapul- 
monary, being produced in the ultimate bronchioles and 
alveoli, and due to the separation of the walls of the 
alveoli, which were more or less firmly agglutinated by 



AUSCULTATION. 117 

tenacious secretions. Others claim they arc caused by 
the bursting of fine bubbles, formed by the forcing out, 
during inspiration, of the secretions from the bron- 
chioles into their infundibuli. Others believe that they 
are extrapulmonary, and are made in the pleura, being, 
in fact, the finest of friction sounds. 

The facts that seem to uphold the latter theory are 
their remaining at the spot where first heard, not being 
influenced by coughing; that they are usually heard 
only with inspiration, but may occur with expiration; 
and that a forcible pressure by the ear or stethoscope 
upon the chest wall during expiration will often cause 
them to be heard with expiration, when before they were 
only detected with inspiration. While production of the 
crepitant rales in the bronchioles and alveoli is possible, 
their pleural origin is more probable. 

These rales have a special importance, as they have 
been considered diagnostic of the first stage of croupous 
pneumonia, occurring even before changes in the res- 
piratory murmur. In this disease they have also been 
called the "rale indux," and confusion has occurred by 
considering them also the "rale redux." 

They occur also over the seat of catarrhal pneumonia, 
caseous tubercular pneumonia, infarctions, oedema of 
the lung and atelectasis. 

Dry crepitations are frequently heard at the base of 
the lung in persons who have been long confined to the 
recumbent posture, and in those in whom there has been 
superficial breathing. They are most apt to be heard 
after the fortieth year, and disappear after two or three 
full breaths have been taken. These rales are caused 
by the action of lung that has been for some time in 
the quiescent state. 

Classification of Moist Kales. — The most rational di- 
vision of the moist rales is, according to their size, into 
small, medium and large rales. 

Appreciation of the size of a rale is important, as it 
indicates (a) the size of the bronchus in which the 



118 THE RESPJRA TOR Y SYSTEM. 

sound is made ; (b) it is diagnostic of the extent of the 
disease, and whetlier or not further pathological changes 
have occurred beyond the mere presence of more or less 
fluid secretion in the tubes. 

The size of the rale should always be considered in 
conjunction with its intensity and nearness to the ear. 
The larger the rale, the larger should be the space in 
which it is made, and consequently it should give the 
impression of being more or less distant from the 
surface. 

If, on the other hand, there is heard over a region 
where the bronchi are normally small, as at the apex or 
base, fairly large-sized rales, but at the same time 
appearing to be close to the surface, it indicates that 
there has occurred dilatation of the bronchi (bron- 
chiectasis), or destruction of pulmonary tissue, and the 
formation of cavities of greater or less extent. 

The small moist rale, in addition to its size, differs 
from crepitations or the "crepitant rale" in the follow- 
ing: (a) The liquid character is more marked. 
(b) While heard chiefly with inspiration, it is also 
present during the first part of expiration, and may 
persist throughout, (c) It is influenced by coughing, 
at times disappearing when the bronchi are clear of 
their fluid contents ; at other times appearing when the 
secretion is forced from the alveoli into the bronchi. 

The designation by some authors of these relatively 
large moist rales as "crepitant" has led to much con- 
fusion. 

The small moist rales are divided into two groups, 
according to the quality of their sound. 

While both groups of the small moist rales are due to 
the presence of fluid secretion in the air-containing 
spaces, the difference in the quality of sound is 
dependent upon the condition of the pulmonary tissue, 
its influence on the conduction of the rale sound to the 
surface, and on its power to modify. 

(1) When the pulmonary tissue is normal, the moist 



AUSCULTATION. 119 

sound made in the bronchi is modified, as is the bron- 
chia] sound that is normally present at the site where 
the rales are made, and they are heard at the surface as 
soft liquid or bubbling sounds. 

Authors have used the terms "bubbling/' "liquid/' 
"mucous/' "submucous/' "non-ringing/' "non-consonat- 
ing" ("klanglos") to describe the sound. 

(2) When there are present changes which increase 
the power of conduction by the tissues, or produce a 
resonating effect, as occurs in increased tension (chil- 
dren), or in pulmonary consolidation due to increase of 
tissue, or the filling of the air spaces by solid exudate 
(pneumonia, tuberculosis, etc.), the rales will be heard 
at the surface with increased sharpness. They will 
have a higher pitch and a crackling, explosive or ring- 
ing quality. 

Hence the names "dry," "crackling," "crepitating 
moist rale," "humid, crackling," "explosive moist rale," 
"subcrepitant," "ringing/' "consonating" ("klingend"), 
given to describe this character of sound. 

Rales in group 2 are usually associated with percus- 
sion, palpation and auscultatory signs that indicate the 
pathological conditions. 

When this type of rale is not attended by these con- 
firmatory signs, the quality is due to the tenacious 
character of the secretions. 

The medium and large-sized rales are also divided 
into two groups, and present the same general characters 
as the small, but are larger-sized and are heard during 
Expiration to the same extent as during inspiration. 

The largest of the moist rales have received several 
names to denote their association with certain patho- 
logical conditions. 

Gurgles are produced in cavities partially filled 
with fluid, where the bronchus enters below the level of 
the fluid. They may be present during inspiration and 
expiration, or may be induced only by coughing. They 
are large, liquid, bubbling sounds, with a peculiar hoi- 



to 



1 20 the in:sriu. i tor y system. 

low ringing qualify, which distinguishes them from 
other moist rales of the same size. 

A I rcous clicks are sounds which may he imitated by 
whispering the word "click." They generally occur 
singly, and are short, snappy, sticky sounds, heard only 
during inspiration. Their mode of production is still 
in doubt, but they are generally associated with soften- 
ing of tubercular deposits. This term is gradually 
falling into disuse, as these rales are not considered to 
have the diagnostic significance which was formerly 
given them. 

Metallic tixkle is a single loud, high-pitched 
sound, with a marked echo quality, and is produced in 
large cavities with thin, tense walls. The peculiar echo 
quality of the sound is due to reflection or reverberation 
in the cavity. While heard with greatest distinctness 
in pyopneumothorax, it may occur over a large pul- 
monary cavity, when it is called "amphoric echo." 

Sitccussiotst sound is a splashing sound that occurs 
when the pleural cavity contains air and fluid. 

This sign may be induced by giving the patient a 
quick, short shake, or by coughing. While the sign is 
present in pneumo-hydro- and pneumo-pyothorax, it 
may occur in cavities of the lung when of large size and 
filled with fluid. 

(3) Friction Sounds. — In normal conditions the move- 
ment of the two surfaces of the pleura on each other is 
unattended with any sound, but in diseased conditions 
rales of various kinds may be produced. 

(a) Dry Feictioxs or Crepitatioxs. — When the 
surface becomes abnormally dry, the to and fro move- 
ments are attended with a dry rubbing sound, similar to 
that produced when the dry surfaces of the hands are 
passed lightly over each other, or it may be like the 
crepitations described above under moist rales. 

Dryness of the pleura occurs during the first stage of 
its acute inflammation and when a large amount of fluid 
has been lost from the body, as in excessive diarrhoea of 
the choleraic type. 



AUSCULTATION. 121 

(h) Moist Crepitations. — When the pleurae are 
covered with a tenacious secretion which glues the two 
surfaces together, their separation is accompanied by 
sticky, moist, crackling, crepitating rales. This type 
frequently replaces the dry rales, as the plastic exuda- 
tion is poured out after the first stage of inflammation. 

(c) Rubbing, Rasping, Grating, Grazing, Creak- 
ing, Leathery Sounds. — These occur when the 
surfaces of the pleura are roughened by exudation, by 
inflammatory changes or joined together by bands of 
a (11 lesions. These rales may be felt by the patient, or 
detected by the hand or ear as fremitus. 

As the pleural rales depend upon the movement of the 
thorax, they will be heard with the greatest intensity 
over the lower segment of the thorax at the end of 
inspiration and at the beginning of expiration, as the 
play of the pleura is greatest during these portions of 
the respiratory act. 

When due to a sticky exudation, deep breathing fre- 
quently causes the rales to disappear. They can be 
heard again after quiet breathing and when pressure is 
made on the chest wall so as to increase the friction. 

Differentiation of Pleurae from Bronchial 
Raxes. 

In certain cases it is impossible, by the quality or size 
of the rale, to separate the pleuritic from the bronchial 

rales. 



Pleural. 
Localized. 



Generally unilateral. 
Frequently accompanied by 
pain. 

They give the impression of 
being produced close to the ear. 



Bronchial. 

Not generally localized, but if 
so, they are associated with signs 
of bronchitis, or consolidation. 

Very apt to be bilateral. 

Generally no pain. 

They seem more or less distant 
from the surface. 



122 



THE RESPIRATORY SYSTEM. 



Usually increased by coughing 
or deep breathing. 

They are localized at the point 
where first heard. 

Their intensity may be in- 
creased by pressure upon the sur- 
face. 

Occur in showers or bunches, 
and all of uniform size. 



Frequently disappear after 
coughing or deep breathing. 

The location changes frequently 
as the result of coughing. 

Unmodified by such pressure. 



Various sizes may he heard at 
the same time. 



It must be borne in mind that pleuritic and bronchial 
rales may be present at the same time. 

(4) Indeterminate, or Indefinite Rales. — In addition to 
the dry, moist and friction rales, another class has been 
recognized under the title of "indeterminate" or "indefi- 
nite" rales. They are crepitating, crumpling, crack- 
ling sounds, moist or dry, heard over various portions 
of the thorax during inspiration, expiration, or both. 
The origin and mode of production of their sound are 
doubtful. 

They include the muscle sounds and the so-called 
emphysematous crackle. Some authors include in this 
class all rales that cannot be definitely determined as 
bronchial or pleuritic in origin. 



CHAPTER VI. 
AUSCULTATION (Continued) 



(A) CONDITIONS MODIFYING AERIAL VIBRATIONS 

AND CONDUCTION OF SOUND BY THE 

COLUMN OF AIR. 

Movement of Tidal Air. 

As the respiratory sounds depend primarily upon the 
movement of air through the glottis and bronchial tract, 
they will be influenced by the amount of tidal air, the 
force of the current, and the rapidity of its movement. 
These factors will influence chiefly the vesicular quality 
of inspiratory sound and the intensity and duration of 
both respiratory sounds. 

When the breathing is deep, and at the same time 
more rapid than normal, the inspiratory sound is 
sharper in quality and more intense, while the expira- 
tory has a more blowing quality, and its intensity is 
accentuated. When the muscles of expiration aid the 
normal elasticity of the lungs, the duration of the 
expiratory sound may nearly equal that of the inspira- 
tory. When this type of breathing is general, it is 
called exaggerated breathing. 

When the respiratory function of one lung is inter- 
fered with from any cause, as pneumonia, pleurisy with 
effusion, etc., and the unaffected lung is doing more 
work in consequence, the breathing over the unaffected 
side is called compensatory breathing. 

Exaggerated or compensatory breath sounds may be 



124 THE RESPIRATORY SYSTEM. 

limited to one lobe, as when pneumonia affects the other. 
They may be limited to a portion of a lobe. This occurs 
(a) when a bronchus is plugged, or (b) when some of 
the lobules are filled with inflammatory exudate. In 
such cases the unaffected lobules on this division of the 
bronchial tree accommodate not only their own normal 
quantity of tidal air, but also that which should go to the 
affected part ; and not only is the current stronger, but 
there is overdistension of the alveoli, increased tension 
and resultant change in the vesicular murmur. 

Localized exaggerated breathing in any portion of the 
lung always indicates compensatory action, and is there- 
fore an important diagnostic sign. 

Conditions which diminish the amount of tidal air, 
weaken its force, or slow the current, will cause a 
diminution of the breath sounds heard at the surface. 

These conditions may be due to changes (a) in the 
bronchial tract, as in certain stages of bronchitis ; (b) in 
the parenchyma of the lung, as in emphysema ; (c) in 
the pleura, as adhesions or fluid; (d) in the bony 
thorax, as increased rigidity; (e) in the soft parts, as 
feeble muscular action. 

In some individuals the normal vesicular murmur is 
so faint during quiet breathing that it can scarcely be 
appreciated. This may be due to the manner of breath- 
ing or to anatomical conditions of the larynx. In such 
cases it is necessary for the patient to take deep breaths 
in order to obtain the breath sounds. 



Influence of the Larynx. 

As has already been noted (page 99), the normal 
vesicular murmur will vary within wide limits, but will 
always have a definite relation to the character and 
intensity of the sound heard over the glottis, which 
forms the basis of all breath sounds present in the 
lung; so that as each voice has its own individual 
quality by which it is recognized, so also will the char- 



AUSCULTATION, "J 2 5 

actor of the respiratory sounds differ. Therefore, when 
the question arises whether or not the breath sounds are 
within the range of normal, the laryngeal sound should 
always be taken as a guide. 

Morbid conditions of the larynx will modify the 
breath sounds in either inspiration or expiration, or in 
both. 

As has been shown, the inspiratory portion of the 
vesicular murmur is composed not only of sounds made 
in the larynx, but also of those made in other portions 
of the bronchial tract and at the alveoli, while the 
expiratory portion depends entirely on the conduction 
to the surface of the sound made at the larynx. There- 
fore, any changes made in the character or intensity of 
the glottic sound will be most marked in the expiratory 
murmur. 

The laryngeal sounds may be increased by anything 
which narrows the opening or changes the relation of the 
parts. The change in the breath sounds produced may 
be limited to one or both portions of the respiratory act. 
Narrowing of the glottis, depending upon malignant or 
non-malignant growth, tuberculosis and syphilis, may 
cause greater or less change in the quality of the sound, 
so that the respiratory murmur heard at the surface of 
the chest will have a peculiar harsh, blowing quality. 
Paralysis of the vocal cords diminishes the size of the 
lumen of the glottis and produces change in the quality 
of the sound, but it is not as marked as in morbid 
growths ; and while the quality of the sound is changed, 
it lacks the harshness. Inflammatory thickening and 
exudations (oedema glottidis) produce the same changes 
as new growths. Croup (laryngeal diphtheria) and 
spasmodic conditions of the larynx produce a form of 
stridor, which, on account of its musical quality, may 
mask the vesicular element of the breath sounds so that 
the only sound heard over the surface of the chest will 
be more or less bronchial in type. It must be especially 
remembered that the introduction into the larynx of 



126 THE EESPIRA Ton Y 8 YSTEM. 

intubation tubes, or the presence of a tracheotomy tube, 
may cause the breath sound beard over the lung to be 
distinctly tubular. This frequently causes the diag- 
nosis to be made of secondary pneumonia, and a corre- 
sponding gloomy prognosis in cases of diphtheria in 
young children. 

It will be diminished by conditions which will hold 
apart the vocal cords. 

Especial care must be taken in judging of the pul- 
monary condition by auscultatory signs when disease of 
the larynx, which causes a diminution of the glottic 
sound, is present, as the effect of changes in the 
laryngeal sound may be so marked as to prevent bron- 
chial breathing being produced in well-marked consoli- 
dation of the lungs. 

Influence of the Bronchi. 

The condition of the bronchial tubes may modify the 
respiratory sounds in their normal elements, or add new 
sounds, as adventitious sounds of rales. 

When the lumen of the tubes is narrowed, either by 
congestion, as in acute bronchitis, by growths within or 
by pressure from without, the intensity of the murmur 
over that portion of the lung which they supply with air 
may be increased or diminished, according as the 
amount and movement of tidal air is influenced. When 
the narrowing causes no diminution in the amount of 
air passing to the lung beyond, then, on account of the 
narrowing, the movement of the air through the nar- 
rowed portion will be more rapid and forcible. 
Inspiration will be harsher in character, while expira- 
tion will be more blowing, higher pitched and of longer 
duration. 

If, on the other hand, changes in the bronchi inter- 
fere with the movement of air, so that it reaches the 
bronchioles reduced in amount and force, inspiration 
will be feeble, the vesicular element especially weak, and 
expiration perhaps inaudible. 



AUSCULTATION, 127 

Diminution in the intensity of the respiratory 
murmur is most marked when the smaller bronchi are 
involved. These changes in intensity may be bilateral 
or limited to one lung or a portion of one lung, accord- 
ing to the morbid processes. 

The abnormal or adventitious sounds present in dis- 
eases of the bronchi are the dry and moist rales, accord- 
ing to the changes in the bronchi and nature of their 
contents. 

Dry Rales. — When the lumen of a bronchus is so 
abruptly narrowed, either by contraction of the muscular 
fibres or by thick, tenacious secretion, as to produce con- 
ditions like those of a wind instrument, as the tidal 
air passes over the obstruction into the relatively wider 
lumen beyond, vibrations are set up aud a sound pro- 
duced as in the larynx at the glottis. 

The character of the sound will depend upon the 
degree of narrowing, the size of the tube and the force 
of the current, and the adventitious sound will be added 
to or modify that made at the glottis. 

When the narrowing is relatively slight, the sound 
produced will be of a harsh, blowing, non-musical 
character, similar to that made normally at the larynx. 
At the surface it will have a well-marked bronchial 
character, most marked with expiration, and almost 
identical with that heard when the lung is consolidated, 
from which it is differentiated by the signs noted by 
percussion and. palpation. This sound may occur in 
bronchitis, asthma and pulmonary tuberculosis. In the 
latter disease it may be associated with more or less 
consolidation. 

When the narrowing is more marked, the sound will 
have a more musical quality, being a type of stridor 
already described. 

When the constriction is in a tube of the second or 
third division, it produces a deep-toned, low-pitched, 
musical sound (sonorous rale). 

When in the smaller tubes, the sound is shriller, 
higher pitched, whistling (hissing or sibilant rale). 



1^8 THE RESPIRATORY SYSTEM. 

The division into sonorous and sibilant rales is an 
arbitrary one, and one type merges into another, accord- 
ing to the size of the tube and nature of the obstruction. 

The dry rales arc not permanent, being evanescent, 
appearing and disappearing; now being heard at one 
place, then over another area. 

The effect of these rales on the normal respiratory 
murmur varies according to their number and intensity, 
and whether or not the constriction is so marked as to 
interfere with the movement of tidal air and prevent 
the production of the normal vesicular element. 

The persistence of the vesicular sound is an important 
diagnostic sign, indicating the degree of obstruction. 
Students frequently fail to appreciate the vesicular 
murmur even when present, as the sibilant and sonorous 
sounds are so striking as to engross the attention. 

The special significance of these rales being heard in 
inspiration or expiration, or limited to one or the other, 
will be considered under the diseases. 

Moist Rales. — When the bronchi are more or less filled 
with fluid, there will be present the different varieties 
of moist rales that have already been described (page 
115). 

The conditions that produce dry and moist rales may 
affect the entire bronchial tract, as in general bronchitis, 
or may be limited to one lijng or to a portion of a lobe. 
The wide or limited distribution of the adventitious 
sounds is of important diagnostic value. 

The Effect of Plugging of a Bronchus. — Complete 
closure of a bronchus by compression from without, as 
by an enlarged gland or aneurism, by the plugging 
with secretions or plastic exudation, as in bronchitis and 
pneumonia, or by a growth within the tube, as in tuber- 
culosis, produces marked diminution or complete 
absence of the breath sounds, according to the site of the 
obstruction. It influences the production of sound by 
the tidal air and the transmission by the tissues. Vibra- 
tions that are present in the column of air are arrested 



AUSCULTATION. 129 

a1 the point of occlusion, and as there is no movement 
of air beyond that point, no sound is made at the junc- 
tion of the alveoli with the infundibuli, and conse- 
quently the vesicular quality of the respiratory murmur 

is wanting. 

Important changes occur in the area that is supplied 
by the occluded bronchus. The air beyond the obstruc- 
tion is rapidly absorbed, and when the plug acts as a 
ball valve the air may be forced out during expiration, 
but not replaced during inspiration. Removal of air 
causes relaxation of the lung, and more or less complete 
atelectasis. As will be shown later, this loss of tension 
causes the tissue to be a poor conductor of vibrations, 
and the expiratory portion will be especially feeble or 
absent. 

When a large bronchus is occluded, no sound will be 
heard over the portion supplied, so that even bronchial 
breathing may be absent in complete consolidation of the 
lung, as in croupous pneumonia. If a small branch 
only is involved, then feeble breath sounds may be heard 
over the affected area, and, the surrounding portion of 
the lung being overdistended, exaggerated or compen- 
satory breathing is present. (Fig. 25.) 



(B) CONDITIONS MODIFYING TISSUE VIBRATION 

AND THE CONDUCTION OF SOUND 

BY THE TISSUES. 

The Influence of Tension. — The elasticity of the tissues 
of the respiratory tract and their degree of tension has 
an important effect not only on the intensity, but also 
on the quality and pitch of the breath sounds. 

When the elasticity and tension are increased, the 
tissues are more easily influenced by the aerial vibra- 
tions present in the bronchi and air spaces. The 
vibrations are shorter; the tissues become better con- 
ductors of sound ; the inspiratory sound is consequently 
more intense, has a sharper vesicular quality and the 
9 



1 : > ( > THE EESPIMA TOR Y SYSTEM. 

pitch will be slightly raised. The expiratory sound is 
louder, more intense, is longer, lias a more marked blow- 
ing quality, often with a suspicion of a bronchial ele- 
ment. Age lias an important effect on the elasticity and 
tension of the respiratory apparatus. In the child not 
only is the resiliency of the tissues greater, but up to 
twelve years of age the relatively more rapid develop- 
ment of the thorax than the lung causes the tension to 
be much greater than in the adult, and is one of the fac- 
tors that causes the respiratory sounds in children to be 
distinctive enough to be called "puerile breathing" and 
stand out as a type. 

Exaggerated or compensatory breathing is due to 
increased tension, as well as to changes in the volume 
and force of the tidal air. 

With advancing years, and when pathological changes 
occur, as in emphysema, there is a loss of elasticity ; 
and, although the lung may be distended beyond the 
normal, there is a lowered tension, and the respiratory 
sounds are feeble and lower pitched; inspiration is 
shorter, while expiration is prolonged. 

Influence of the Increase of Tissue in the Walls of the 
Bronchi and Alveoli on the Respiratory Sounds. — When 
considering the production of normal vesicular murmur, 
it was stated that the thin, membranous structure 
of the walls of the bronchioles and alveoli was chiefly 
influenced by the vibrations of the air contained in 
them ; also that this tissue was a poor conductor of the 
vibrations brought to it from above through the more 
solid tissues of the walls of the bronchi, and that these 
facts accounted for the absence of the bronchial or 
tubular sound in the normal respiratory murmur. 

When the normally light membranous structure of 
the periphery of the lung is changed into denser con- 
nective tissue, as occurs in interstitial or fibroid changes 
in the interlobular septa (in interstitial pneumonia, 
fibroid phthisis and certain types of pulmonary tuber- 
culosis), the new tissue, being more homogeneous with 



AUSCULTATION. 131 

the walls of the larger bronchi, will conduct the bron- 
chial sound from the deeper portion of the lung direct 
to the surface. The change may he so slight as only to 
give a slightly prolonged expiration. The ear may 
detect two types of breathing in varying proportions — 
the normal vesicular murmur and an added bronchial 
element, most marked in expiration. This mixed 
breathing is called broncho-vesicular. The proportion 
and character of the tubular quality will depend upon 
(a) the amount of new tissue; (b) the extent of its 
penetration into the lung and the size of the bronchial 
tubes reached. 

Broncho-vesicular breathing varies from the faintest 
tinge of the bronchial sound to that in which the tubular 
sound predominates, and the vesicular element can only 
be faintly detected. (Fig. 25.) 

When the air in the alveoli is replaced by coagulated 
exudate or tissue, as occurs in pneumonia, hemorrhagic 
infarction and tubercular infiltration, then during 
inspiration the vesicular quality is absent, because there 
is interference with the amount and force of tidal air, 
and the aerial vibrations are unable to modify the tissue 
vibrations present. The consolidated lung, being a 
good conductor, allows the bronchial sound present in 
the deeper portion of the lung to be heard. 

When the consolidation is very slight, the sound from 
both the normal and consolidated lung is brought to the 
ear, so that the only change noted may be limited to a 
prolongation of expiration, with a slight raising of the 
pitch, L e., the faintest type of broncho-vesicular breath- 
ing. 

If the consolidation reaches only to the small bronchi, 
then the breathing, while bronchial, is of a soft, blowing 
quality; the pitch is raised; the intensity corresponds 
to the pitch, and the expiratory sound is prolonged, 
more tubular and higher pitched than the inspiratory, 
and a short pause is noticed between inspiration and 
expiration. 



132 THE RESPIBA TOE Y SYSTEM. 

When a medium-sized tube is involved, the quality 
will be more bronchial; the pitch will be higher; the 
intensity greater; the expiratory sound will be higher 
pitched and longer than the inspiratory, and will have 
a more markedly tubular character. This is usually 
described as bronchial breathing. 

When an entire lobe is involved, then the sound heard 
is that conveyed from the large bronchi. It has all of 
the characteristics of that heard normally over the 
trachea, and is called pure bronchial, tubular or tracheal 
breathing. 

The auscultatory signs heard at the surface in con- 
solidation of the lung, whether due to fibrosis of the 
stroma or filling of the air spaces, are not always as 
typical as has just been described. 

When the consolidated portion reaches the surface, 
and is immediately beneath the ear, then the breathing 
will be typical of the pathological changes, but when it 
is deeper and is covered by lung that is normal, or in a 
state of compensatory distension, the bronchial element 
may be entirely masked by the normal or exaggerated 
breath sound of the overlying portion of the lung, or it 
may be faintly detected, especially in expiration, where 
the first part has a fairly normal quality, but the latter 
part is prolonged, high pitched, more blowing and 
bronchial. (Fig. 25.) 

This type of breathing, according to the intensity of 
the bronchial sound, as has been described as "broncho- 
vesicular breathing," "prolonged, high-pitched expira- 
tion" or one of the types of the so-called "metamorphos- 
ing breathing." 

The influence of changes occurring in the pleura on 
the bronchial breathing of consolidation will be con- 
sidered later. 

Influence of the Increase in the Size of the Air-Containing 
Spaces (cavity formation and bronchiectasis) — The destruc- 
tion of lung tissue and the formation of cavities, which 
are at least partly empty and connect freely with a 



AUSCULTATION. 133 

bronchus, cause a modification of the bronchial breath- 
ing, which is called cavernous or amphoric, according to 
the dimensions of the cavity, the condition of the tissue 

forming its walls and the size of the bronchus opening 
into it. 

Much confusion will be avoided if it be remembered 
that tubular, cavernous and amphoric are all types of 
bronchial breathing; that they vary in degree, and often 
approach each other in character. While they have a 
general resemblance, the differentiation is made by the 
quality and pitch of the sound. 

The bronchial sound that is brought to the cavity is 
resonated, as when one blows over the mouth of a bottle. 
When the walls of the cavity are flaccid and of low ten- 
sion, a peculiar hollow sound is produced, which is 
called cavernous. The inspiratory portion is soft, 
blowing, hollow, but less tubular, and lower pitched 
than the tracheal sound. The expiratory is more blow- 
ing, wavy or puffy ; the pitch is lower than that of the 
inspiratory, which distinguishes it from bronchial 
breathing, in which the pitch of expiratory is higher 
than that of the inspiratory sound. 

The sound heard over the trachea, behind, serves as a 
standard for bronchial breathing with which to compare 
doubtful cavernous breathing. 

When the walls of a cavity are rigid and tense, as 
when composed of dense, fibrous tissue, when sur- 
rounded by consolidated lung, or when bound to the 
chest wall by firm pleuritic adhesions, the sound pro- 
duced is amphoric. 

It is a hollow, blowing sound, similar to the cavern- 
ous, but has a harsh, metallic or slight echo quality. 
The tubular element is more marked, but less than in 
bronchial breathing, and the expiratory sound has a 
lower pitch than that of inspiration. 

The terms cavernous and amphoric, used to designate 
the breath sound, heard over cavities, are sometimes 
uncertain in their application, owing to the individual 



1 34 THE EE8PIB. i TOE Y SYSTEM. 

interpretation of the sound heard. This is due to the 
fact that the walls of cavities vary in tension. A type 
of breath sound is frequently heard which has the quali- 
ties of the cavernous and amphoric breathing in vari- 
ous degrees, and may be called caverno-amphoric or 
amphoro-cavernic, as either type predominates. 

When the cavity is filled with fluid or the bronchus 
leading to it is occluded, cavernous or amphoric breath- 
ing may be absent, either temporarily or permanently. 

When a bronchus opens freely into the pleural cavity 
filled with air, a peculiar, intense type of amphoric 
breathing is heard. This has been called the "lung 
fistula sound. 7 ' 



(C) CONDITIONS MODIFYING VOCAL RESONANCE. 

The difference in the sounds heard over the chest 
when a person breathes, whispers or speaks depends upon 
the character of the vibrations made at the glottis. 

Whispered Voice or Whispered Resonance. 

In order to intensify the sound made at the larynx, 
the patient may be instructed to breathe noisily, or, 
what is better still, to whisper with different degrees 
of loudness. The whispered voice, in addition to being 
more intense than the breath sound, gives the articu- 
late elements of speech — the consonants. The clearness 
with which they are heard over the different regions of 
the chest indicates the extent and degree of the changes 
that have occurred in the power of the lung to conduct 
sound to the surface. 

The whispered voice is heard with expiration, and 
when patients are too weak to take deep breaths we can 
increase the intensity of the sound heard on expiration 
without exhausting the patient by having him whisper. 

Normally, the whispered words are conveyed to the 
ear as soft, diffuse, indistinct sounds. Over those por- 



AUSCULTATION. 135 

tions of the lung where tracheal, laryngeal and bronchial 
breathing normally exist, the whispered words are heard 
with greater distinctness, and the words will be recog- 
nized more or less completely. 

Conduction of the whispered voice will be increased 
or diminished in the same manner and under like condi- 
tions as the breath sounds. It is especially valuable to 
determine the presence of a slight amount of consolida- 
tion, when the whispered words will be brought to the 
ear with increased distinctness. 

As consolidation increases in extent and involves the 
larger tubes, the whispered words become more and 
more distinct, until it is possible not only to recognize 
the whispered words or numbers (whisper-bron- 
chophony), but also to detect the articulate parts of 
speech, as the consonants (whisper-pectoriloquy). 



The Spoken Voice or Vocal Resonance. 

The vibrations of the spoken voice are so powerful 
as to influence the entire amount of air within the 
bronchi and alveoli, so that they are not only heard at 
the periphery as normal resonance, but are also felt as 
fremitus. The open bronchi, with their tense, elastic 
walls, act as speaking tubes, and the sound made at the 
glottis is modified in its conduction to the surface, as 
follows : ( 1 ) By reflection, reverberation or echo 
within the tubes, so that confusion of the sound occurs, 
(2) By diffusion in the ramifications of the bronchi 
and alveoli, so that it is weakened or less intense. 

In the larynx and trachea little change occurs in the 
sound, except that the consonants are not heard as 
distinctly, but the intensity of the sound seems to be 
slightly greater than at the mouth. 

In the larger bronchi, as heard over the sternum and 
parasternal portion of the infraclavicular space in front, 
and upper portion of the interscapular space behind, the 
sound is more indistinct, the words are blurred, but still 



13G THE BESPIR. I TOR Y SYSTEM. 

distinguishable, and the pitch of the sound is slightly 
higher than in the trachea. 

This sound is called "normal bronchophony," and 
may be heard over other regions of the chest when con- 
solidation of the lung tissue transmits it unmodified to 
the surface. 

With each division of the bronchi the sound is still 
further reflected, confused and weakened, as were the 
breath sounds, until at the surface of the lung the 
articulate parts of speech are absent ; the words are not 
distinguishable, and it becomes an indistinct humming, 
buzzing sound, normal vocal resonance. 

Normal vocal resonance will vary in individuals, 
according to the character of the voice, as has been 
mentioned under "Palpation." 

It will be influenced by the same changes in the 
bronchi and alveoli that modify breath sounds and the 
fremitus of palpation. 

Yocal resonance may be absent, feeble or exaggerated. 
Just as in proportion to the pulmonary consolidation, 
the expiratory part of the respiratory murmur varies 
in intensity, pitch and quality, from the faintest 
suspicion of bronchial sound up to pure bronchial 
breathing, so vocal resonance varies in the clearness 
with which the articulate sounds are heard from a 
slight increase of normal resonance up to bronchophony, 
where the words are heard more or less distinctly, but 
confused and associated with vibrations of the chest 
wall. 

Pectoriloquy^ as its name implies, sounds as if the 
patient was speaking directly through the chest, or as if 
we were listening directly over the larynx through a 
solid medium, as a block of w r ood. It is an exaggerated 
form of bronchophony. Its characteristic feature is the 
remarkable distinctness with which the consonants of 
the spoken words are heard. It is best detected with 
the whispered voice, as there is less confusion from 
reverberation. 



AUSCULTATION. 137 

Pectoriloquy is heard over consolidated lung that is 

in a high state of tension, and that extends to the large 
bronchi. 

Over pulmonary cavities two kinds of spoken and 
whispered resonance are heard: (a) cavernous and (b) 
amphoric. 

Cavernous resonance is produced in cavities with 
thin, lax walls. It is a type of bronchophony. The 
sound is hollow, low pitched, and has a puffing, blowing 
character. With the spoken voice, the words are con- 
fused, having a slight echo quality. With the whispered 
voice, the words are more distinct, but not articulate. 

Amphoric resonance occurs in cavities with tense 
walls, and is usually associated with amphoric breath- 
ing. The sound is a type of pectoriloquy, in that it is 
distinctly articulate, with a hollow, ringing, well-marked 
echo quality and high pitch. 

^Egophony is a form of vocal resonance that occurs 
in certain stages of effusion in the pleural sac. The 
voice is not as intense as in bronchophony, but is high 
pitched, tremulous, with a marked nasal sound, so that 
it has been compared to the bleating of the goat ; but it 
is more like the voice of a person with a cleft palate. 
It is not associated with increased vocal fremitus. The 
condition of the lung allowing its production will be 
considered under "Pleurisv with Effusion. 7 ' 



Auscultation of the Cough. 

The sound produced by coughing is frequently util- 
ized in diagnosis, but it is not as reliable as vocal reso- 
nance. In the normal lung it is heard at the surface as 
an indistinct, sharp sound, accompanied by sudden move- 
ment of the chest wall, due to the action of the expira- 
tory muscles. In varying degrees of pulmonary 
consolidation and in cavities it has been named bron- 
chophony, cavernous and amphoric cough, having the 



loo THE RESPIRATORY SYSTEM. 

same features as vocal resonance under similar condi- 
tions. 

On account of the forcible expulsive power of cough, 
a larger amount of air than usual is driven out of the 
lung, and the succeeding inspiration is correspondingly 
increased in volume. This allows slight changes in the 
bronchi and pulmonary tissue to be detected by the 
character of the vesicular murmur. "A post-tussive 
suction sound" or "india rubber-ball sound" is frequently 
heard with the inspiration immediately after the cough 
when cavities with soft, yielding walls are present. It 
is a sucking, semi-sonorous, low-pitched sound, usually 
accompanied by a few mucous clicks or medium-sized 
moist rales. It is a very important and reliable sign of 
cavity formation. 

Coughing has a marked effect on moist rales. When 
the fluid contents of the tube are dislodged, it may cause 
them to disappear entirely, or to change small rales to 
those of larger size. When the secretion is in small 
cavities, with more or less occlusion of the bronchial 
tubes leading to them, no rales may be detected during 
quiet, or even forcible, breathing, but are heard after 
coughing. 

The Beee Sound, Beee Tympany, or Coin Reso- 
nance. — In pneumothorax, or when a large cavity is 
present in the lung close to the surface, if percussion is 
made on the anterior portion of the chest with two 
coins while the auscultator listens behind, there is heard 
over the affected area a distinct ringing bell- or anvil- 
like sound. In order that this air-containing space may 
act as a resonator, it is necessary that it be of a certain 
size, with tense walls. 

Veiled Puff. — This is a short, high-pitched, puffing 
sound, which is added to the inspiratory murmur toward 
the end of inspiration. It has been considered diag- 
nostic of small sacculated bronchiectatic cavities. 



AUSCULTATION. 139 



(D) INFLUENCES OF CHANGES IN THE PLEURA 
ON THE BREATH SOUNDS. 

The normal pleuraj being very thin and almost homo- 
geneous with the tissue of the walls of the alveoli, docs 

not affect the transmission of the respiratory sounds. 
When the pleura is thinly covered with a sticky secre- 
tion, different varieties of friction sounds are heard, 
which may mask the pulmonary sound. 

When the pleural changes cause pain on breathing, 
movement of the affected side is restricted, and there is 
a corresponding decrease in the intensity of the vesicular 
murmur. Generally all increase in the thickness of the 
pleura, whether from plastic exudation or interstitial 
changes, interferes with the transmission of vibrations 
to the surface, and influences the intensity of the breath 
sounds. 

a The motion of sound, like all other motion, is 
enfeebled by its transmission from a light body to a 
heavy one" (Tyndall), so that the vibrations in the 
thin membranous walls of the alveoli are transformed 
into vibrations in the thickened pleura, with loss in 
their intensity which is proportionate to the change in 
the homogeneity or density of the pleura. 

Changes in the pleura, especially the pulmonary por- 
tion, which render it less elastic or distensible, curtail 
the normal inspiratory enlargement of the lung, and 
thus decrease the amount and force of tidal air and 
enfeeble the breath sounds. This effect is especially 
marked over the apices and lower borders of the lungs. 

Collections of fluid, air or the formation of new 
growths in the pleural sac separate more or less widely 
the two surfaces of the pleura, and allow the lungs to 
retract. This produces loss of tension in the pulmonary 
tissue and weakens the vibrations at the surface of the 
lung, so that the breath sounds are heard very feebly 
or not at all. 

The occurrence of bronchial breathing and ipgophony 



1 40 THE RESPIRA TOR Y SYSTEM. 

at the upper level of the fluid effusions will be explained 
under "Pleurisy with Effusion." 

Adhesions between the two surfaces of the pleura 
may cause marked decrease in the breath sounds by 
preventing normal movements and limiting expansion. 

When pleural adhesions keep the pulmonary tissue 
tense, or are associated with increase of pulmonary tis- 
sue, as occurs in interstitial pneumonia and the fibroid 
type of phthisis, they may form homogeneous bands of 
connection between the ribs and the bronchi, and so 
permit the breath sounds to be heard where ordinarily 
they are absent. 



(E) INFLUENCE OF THE THORACIC WALL 
ON BREATH SOUNDS. 

The bony thorax acts as a sounding board for the 
vibrations conveyed to it, and influences the intensity 
of the breath sounds according to its elasticity. At the 
same time, by its rigidity, it affects the movement of the 
ribs and modifies the amount of tidal air and the inten- 
sity and duration of the vesicular murmur. 

The inspiratory portion of respiration being a 
muscular act, its intensity, duration and rhythm are 
easily modified by changes affecting the muscles. 

The rhythm may become irregular, jerky or inter- 
rupted through the imperfect or irregular contraction of 
the ordinary muscles of inspiration. It may be due to 
nervousness of the patient, disease of the nervous sys- 
tem or of the muscles themselves, or to pain either in the 
chest wall or in the pleura. 

Expiratory movement, although normally a passive 
act, may be altered by the muscles of expiration in the 
same manner as inspiration. 

The thickness of the soft parts will also affect the 
clearness with which the respiratory sounds are heard, 
in a manner similar to its effect on vocal fremitus. ( See 
"Palpation.") 



CHAPTER VII. 

DIAGNOSIS OF DISEASES OF RESPIRATORY TRACT. 



BRONCHITIS. 



Bronchitis is an inflammation of the different tis- 
sues of the bronchial tubes. It may be acute or chronic. 
It may involve a limited portion only, as the large tubes, 
or the entire bronchial tract. Primary acute bronchitis 
usually affects the bronchi of both lungs to a nearly 
equal extent. Accompanying or pre-existent disease of 
the lung causes the bronchitis to be limited to a portion 
of one lung only, or to be much more intense on one side 
than on the other. 

Acute Bronchitis. 

The physical signs present in acute bronchitis depend 
on: (1) The size of the bronchial tubes involved. 
(2) The nature and extent of the changes in the mucous 
membrane. (3) The character, amount and distribu- 
tion of the secretion or exudation present in the bronchi. 
(4) The influence of changes in the mucous membrane, 
and the presence of secretion on the movement of air in 
the bronchi. 

As the lumen bronchial tube has a most important 
bearing on the intensity of the physical signs and the 
gravity of the disease, it furnishes a basis for classifica- 
tion of the varieties of bronchitis. Acute bronchitis 
may be divided into : 

A. Bronchitis of the Larger Tubes. — This includes 
involvement of the trachea and the larger cartilaginous 



142 THE RESPIRATORY SYSTEM. 

tubes, whose diameter is so great that the tumefaction 
of the mucous membrane and the presence of more or 
less fluid secretion or inflammatory exudation does not 
cause marked obstruction or interference with the 
movement of air. 

B. Bronchitis of the Middle-Sized Tubes. — An inflam- 
mation of the medium-sized and smaller cartilaginous 
tubes, whose lumen is narrowed to a greater or less 
extent, with a more or less interference with the move- 
ment of air and a corresponding production of physical 
signs. Synonyms. — Simple bronchitis, acute bronchial 
catarrh. 

C. Bronchitis of the Smaller Tubes. — An inflammation 
of the smallest cartilaginous and non-cartilaginous 
tubes down to the lobular bronchioles, and character- 
ized by marked obstruction of the bronchi and imperfect 
ventilation of the lung. Synonyms. — Acute capillary 
bronchitis, acute suffocative catarrh. 

D. Bronchitis of the Smallest Tubes, including lobular 
bronchi, and extending into the intralobular bronchioles 
and air-passages, with tendency to lobular consolidation. 
This is characterized by extreme interference with pas- 
sage of tidal air to and from the alveoli, with imperfect 
oxygenation of the blood. Synonyms. — Capillary 
bronchitis of infancy and old age; capillary bronchitis 
with broncho-pneumonia ; peripneumonia nothia. 

Physical Signs. — As the classification of bronchitis 
given above is largely arbitrary, and as we rarely find 
the disease limited to the different divisions of the 
bronchi, so also the physical signs that are present in 
one variety of bronchitis merge more or less into those 
of the other varieties. It is best to compare the physical 
signs of the different varieties. 

Inspection. — A. Bronchitis of the Larger Tubes. — 
As there is neither change in the pulmonary tissue nor 
interference with the movement of air through the 
bronchi, there is no alteration in the shape and size of 
the thorax. The respiratory movements may be slightly 



DISEASES OF RESPIMA TOR V TRACT. 1 1 3 

increased, both in frequency and depth, but the two 
sides move symmetrically, and expansion is full and 
free. 

/>. Bronchitis of the Middle-sized Tubes. — In mild 
cases no change is noted in the size or form of the 
thorax, and the respiratory movements are but slightly 
increased in force and frequency. In severe cases, in 
proportion to the narrowing of the lumen of the bronchi 
by inflammatory swelling or secretion and interference 
with the free movement of air, the respiratory move- 
ments are more rapid and labored, expansion being 
restricted when tubes of smaller calibre become involved 
and the above signs become increased in intensity. 

C. Bronchitis of Smaller Tabes. — There is a marked 
movement of the upper portion of the chest, with violent 
action of the accessory inspiratory muscles ; the expan- 
sion of the chest is chiefly confined to upper portion ; 
there is loss of expansion in lower portions of the chest, 
and diaphragmatic action is restricted. As the case 
becomes more severe, and the interference with the 
movement of air through the small bronchi becomes 
more marked, two types of dyspnoea may develop. 

( 1 ) Inspiratory Dyspnoea. In this form the greatest 
interference is with air passing into the alveoli ; the 
action of the accessory muscles of inspiration is espe- 
cially great, causing marked elevation of the upper por- 
tion of the chest, while the partial vacuum that is pro- 
duced in the lower portion of the lung causes depression 
of the intercostal spaces, loss of expansion of the lower 
portion of the thorax, and, in infants and young chil- 
dren, yielding of the chest walls, depression of the lower 
ribs and retraction of the abdomen. 

(2) Expiratory Dyspnoea. In this form entrance of 
air into the alveoli is fairly free, and the chief difficulty 
is with the tidal air passing out of the alveoli, due to 
plugging of the small bronchi with secretion or to 
spasm of the bronchi themselves. This gradual over- 
filling of the alveoli (acute emphysema) causes enlarge- 



144 THE RESPIRATORY SYSTEM. 

ment of the thorax; the movements of inspiration are 
short and followed by a pause, while those of expiration 
are prolonged and labored. During expiration the 
accessory muscles are brought into play, and there is 
bulging of the intercostal spaces and supraclavicular 
fossa. 

D. Bronchitis Involving the Lobular Bronchioles and 
Alveoli. — The cyanosis is more marked; the respirations 
are rapid ; from thirty to forty, and may reach sixty, or 
even more, per minute. The dyspnoea is chiefly inspira- 
tory, with deep depression of the supraclavicular fossa 
and intercostal spaces, and, as the bases of the lungs are 
chiefly involved in children, there is marked drawing in 
of the lower ribs, ensiform cartilage and epigastrium. 

Palpation. — A. Bronchitis of Large Tubes. — Sur- 
face temperature slightly raised ; respiratory movements 
normal (free, rhythmical and symmetrical) ; vocal 
fremitus normal, except when larynx is also involved, 
when it is reduced in direct ratio to the lmskiness of 
the voice. 

B. Bronchitis of Middle-sized Tabes. — In mild cases 
the respiratory movements and vocal fremitus are 
within range of normal. In severe cases, with marked 
congestion and tumefaction of the mucous membrane 
and thick, tenacious secretion, the movements are 
slightly more rapid and somewhat labored, vocal reso- 
nance is diminished, and when large bronchi are 
plugged, there is restricted motion over portion of 
lungs supplied by occluded tubes and absence of vocal 
fremitus. Ehonchal fremitus is sometimes present. 

C. Bronchitis of Smaller Tabes. — In mild cases vocal 
fremitus may be normal or slightly diminished. In 
severe cases, in proportion to the obstruction, the move- 
ments will be rapid and labored, and vocal fremitus 
feeble or even absent. In children, and sometimes in 
adults with thin, elastic chest walls, rhonchal fremitus 
is present. 

D. Bronchitis Involving Smallest Bronchioles and 



DISEASES OF RESPIRATORY TRACT. 1 15 

Alveoli. — Vocal fremitus is diminished, or even absent, 
when obstruction is extreme. When inflammation has 
extended to the alveoli, causing consolidations of lung 
(broncho-pneumonia) close to the costal surface, vocal 
fremitus may be increased. 

Pebcussion. — A. Bronchitis of the Large Tubes. — 
As there is no change in the structure or tension of the 
pulmonary tissue or size of the air-containing spaces, 
percussion sound will be normal in quality, intensity, 
pitch and duration. 

B. Bronchitis of the Middle-sized Tubes. — Percus- 
sion sound is normal unless one of the tubes is plugged. 
If the portion of lung supplied by occluded bronchus 
is in contact with costal surface, the percussion sound 
will have a slight tympanitic quality. If the surround- 
ing portion of the lung that is in state of compensatory 
emphysema is reached by percussion, the sound will be 
hyper-resonant. 

C. Bronchitis of Smaller Tubes. — In mild cases 
slight dullness in percussion may be present over lower 
portion of lung. In severe cases over portion of chest 
which is in a state of more or less compensatory 
emphysema, there is a varying degree of hyper-reso- 
nance, while over the lower portion, when there is 
inspiratory dyspnoea, imperfect expansion, collection 
of secretion in bronchioles and alveoli, with partial 
collapse of the lung; there is dullness, with slight 
tampanitic quality. When the dyspnoea is expiratory, 
with distension of the alveoli, there is hyper-resonance. 

D. Bronchitis Invoicing Bronchioles and Alveoli. — 
Over areas of secondary bronchial pneumonia, if near 
the surface and of sufficient size, the percussion is dull 
in proportion to the extent of consolidation. As sur- 
rounding vesicles are frequently in a state of collapse, 
the note may be dull, with tympanitic quality. When 
the consolidated area is small and overlapped by dis- 
tended emphysematous lobules, the percussion note may 
be normal or hyper-resonant. 

10 



146 THE RESPIBA TOR Y SYSTEM. 

Auscultation. — A. Branch Wis of Large Tithes. — Tn 
mild cases there is no change in normal breath sounds. 
In the more severe types of the disease, during the dry 
stage, the normal tubular sound heard over the trachea 
and large bronchi has a harsher quality, due to the 
slight narrowing of the tubes. When secretion is 
present, if tenacious, it may produce local narrowing, 
causing coarse, sonorous rales. If the secretion is more 
liquid, a few large moist or mucous rales, which are 
easily removed by coughing, may be present. In the 
adult marked auscultatory signs are the exception ; in 
children they are present more frequently. Vocal 
resonance is unchanged. 

B. Bronchitis of Medium-sized Tubes. — In mild 
cases the breath sounds over the lung are normal, except 
that during the dry stage the quality is slightly harsher 
and the expiratory part of the sound is longer, but 
unchanged in quality and pitch. When the amount of 
fluid present in the tubes is fairly abundant, large and 
medium-size liquid, bubbling rales are heard during 
both inspiration and expiration. In more severe cases, 
when the lumen of the bronchi is narrowed by the con- 
gested and swollen mucous membrane during the dry 
stage, the respiratory murmur is less intense than nor- 
mal during inspiration, while in expiration it is pro- 
longed and has a faintly sonorous quality, which may 
be mistaken for a type of bronchial breathing. From 
this it is differentiated by being heard over both lungs 
and by the absence of the associated signs of consolida- 
tion, dullness and increased vocal fremitus. When the 
fluid is abundant and tenacious, sonorous and sibilant 
rales and rhonchi are present. These adventitious 
sounds may mask the respiratory murmur ; they are apt 
to be inconstant, are easily changed in character by 
coughing and deep breathing, and are heard over both 
lungs with equal intensity. When the secretion is more 
liquid, dry rales are less prominent, and heard chiefly 
over the upper portion of the lung, while large and 



DISEASES OF RESPIRATORY TRACT. 147 

medium-sized liquid, bubbling rales predominate. They 
are most abundanl at the base, as the secretion tends to 
gravitate to the most dependent portion of the lung, 
especially in children and feeble adults. As the 
smaller tubes become involved, either by extension of the 
inflammation or by gravitation of the secretions into 
them, the dry rales become more sibilant and the moist 
rales finer and more crepitating. Vocal resonance is 
normal or slightly diminished. 

C. Broncliitis of the Smaller Tithes. — The respiratory 
murmur may show very little change during the dry 
stage ; the intensity of inspiratory sound is diminished, 
the quality being somewhat harsher and dry, the pitch 
unchanged. The expiratory sound is more intense 
than that of inspiration; the sound is prolonged, and 
may have a harsher, blowing quality. When liquid is 
present, sibilant rales and smaller mucous rales accom- 
pany both sounds. In direct proportion to the severity 
of the case, the respiratory sounds are diminished in 
intensity, and may be obscured and replaced by hissing, 
sibilant rales and small liquid rales and crepitations. 
As the secretion accumulates in the bronchi, it tends to 
gravitate to the lower part of the lung, so that over this 
portion the small, bubbling and crepitating rales will be 
most marked, while over the upper portion of the luns; 
the moist rales will be coarser and the sibilant rales 
more abundant. 

D. Bronchitis Involving the Lobular Bronchioles and 
Alveoli. — Extension of inflammation into the lobular 
bronchioles and alveoli (broncho-pneumonia) is shown 
by the more or less intense bronchial quality of the 
breath sounds, especially marked during expiration; 
the rales heard over the areas of bronchial breathing are 
finer, more ringing or crepitating than those heard in 
simple bronchitis, and are most abundant just at the end 
of inspiration. Vocal resonance is increased over areas 
of consolidation. 

Differential Diagnosis. — The diagnostic features of the 
different varieties of acute bronchitis are: (1) There 



148 THE RESPIRATORY SYSTEM. 

is a bilateral distribution of all the physical signs. (2) 
In proportion to the severity of the disease, the smaller 
bronchi become involved, giving more marked physical 
signs over the lower portion of the chest. (3) The 
physical signs detected are those due to changes in the 
bronchial tubes only, i. e., the presence of rales of vary- 
ing size and interference with the movement of tidal air. 

The diseases with which acute bronchitis is most 
liable to be confounded are : 

Broncho-Pneumonia (Acute Catarrhal Pneumonia). — In 
both diseases the signs are bilateral, most intense at 
the base of the lung, and there are numerous rales. But 
in broncho-pneumonia there is not the same uniformity 
of distribution. Broncho-pneumonia gives, over the 
area of consolidation, increased vocal fremitus. Uncom- 
plicated acute bronchitis, diminished vocal fremitus. 
Broncho-pneumonia, dullness of varying degree, accord- 
ing to amount of lung involved. Bronchitis, but slight 
change in resonance. Broncho-pneumonia, bronchial or 
tubular quality of the breath sounds, which is absent in 
bronchitis. 

Acute Diffuse Pulmonary Tuberculosis. — The physical 
signs in this disease are bilateral, and at the beginning 
are almost identical with those of capillary bronchitis 
with small areas of broncho-pneumonia, but the general 
constitutional symptoms are graver. As the disease 
advances, the physical signs become more distinctive. 

Inspection. — Tuberculosis : Respirations are more 
rapid; cyanosis out of proportion to dyspnoea ; restricted 
motion over the entire chest. Retraction of the thorax 
most marked over upper portion of lung, and more 
marked at one apex than the other. Bronchitis: 
Retraction most marked over the lower lobes ; generally 
increased fullness of upper portion of the chest in pro- 
portion to the retraction at base. 

Palpation. — Tuberculosis : Vocal fremitus may at 
first be diminished ; later increased with extension of 
consolidation. Simple bronchitis : Vocal fremitus 
normal or slightly diminished. 



DISEASES OF RESPIRATORY TRACT. 1 19 

Percussion. — Tuberculosis : Resonance early im- 
paired, with slight dullness, due to change in the alveoli, 
and early pleuritic involvement.. Dullness is most 
marked over the upper portion of the chest; there is 
increased sense of resistance over the part involved. 
Bronchitis: Percussion normal or hyper-resonant. 

Auscultation. — The differential diagnosis rests 
chiefly on the course of the disease and the distribution 
of the rales. While in acute bronchitis, with the 
dyspnoea and cyanosis, there is a corresponding* number 
of dry and moist rales, most marked at the base, in 
tuberculosis the number of moist rales is comparatively 
few, and they are as numerous, or even more so, at the 
apex as at the base ; also there is generally an uneven dis- 
tribution of the rales on the two sides. Later there is a 
tendency for the signs of consolidation to become more 
marked over different areas of the lung, and to be fol- 
lowed by signs of diffuse softening and cavity formation. 
Frequently it is possible to find in some portion of the 
lung, especially at the apex, an old focus, with its char- 
acteristic physical signs of long-standing consolidation. 

Pulmonary (Edema. — The differential diagnosis of 
bronchitis from pulmonary oedema rests chiefly on the 
order of occurrence of moist rales. In acute bronchitis 
the larger tubes are primarily involved, and the rales 
first detected are those of large size. With the extension 
of the disease into smaller bronchi, rales of correspond- 
ing size are also present, and are heard over the entire 
lung. In pulmonary oedema fluid collects in the alveoli, 
and fine crepitating rales are first heard over the lower 
borders and base of the lung. The larger rales are only 
present when the oedema is extensive. 

Chronic Bronchitis. 

The physical signs of chronic bronchitis, when only 
the mucous membrane is involved, are similar to those 
of the acute variety. Long continuance of the cough 



ISO THE RESPIRATORY SYSTEM. 

interferes with the function of the lung, and repeated 
attacks of acute or subacute bronchitis develop secondary 
changes in the bronchi, alveoli and pulmonary tissue. 
These changes determine the different types of chronic 
bronchitis and cause its symptoms and physical signs 
to be more or less characteristic of the secondary 
changes, (a) bronchiectasis, (b) asthma or spasmodic 
bronchitis, (c) emphysema, (d) fibroid or interstitial 
pneumonia. 

Types or Varieties of Chronic Bronchitis. — A. Simple 
chronic catarrh of the large tubes (winter cough) ; 
characterized by cough and slight expectoration, with 
tendency to intercurrent attacks of acute bronchitis. 
The structures of the lung are but slightly changed from 
the normal. 

B. Dry catarrh ; characterized by very little secretion 
from the mucous membrane, by constant or persistent 
cough, scanty or difficult expectoration, presence of 
dyspnoea. The constant and violent attacks of coughing 
early induce emphysematous change, and acute attacks 
of bronchitis may cause it to assume temporarily the 
physical signs of the spasmodic type. The physical 
signs are those of acute bronchitis during the dry stage. 

C. Bronchitis with* abundant secretion. Under 
this may be included (1) bronchorrhcea, of which two 
types are recognized, (a) cases in which the secretion is 
thin, watery, slightly tenacious, resembling the white 
of an unboiled egg. Severe paroxysmal attacks of 
coughing and dyspnoea occur in the morning, and may 
last for one or two hours, after which the chest is clear ; 
or they may be repeated at longer or shorter intervals, 
followed by complete relief. From the character of the 
symptoms and expectoration, the names "mucoid asthma" 
and "bronchorrhcea serosa" have been given, (b) Cases 
with sero-purulent or muco-purulent expectoration, 
attended with almost constant coughing and frequent 
attacks of paroxysmal dyspnoea. These attacks rapidly 
induce structural changes in the lung of the emphysema- 



DISEASES OF RESPIMATOBY T&ACT. 151 

tons, bronchiectatic and fibroid types. (2) Fetid bron- 
chitis. In this the secretions have undergone decompo- 
sition, and may occur in bronchi that have not been 
dilated, but is most frequently dependent upon dilata- 
tion of the bronchi and long retention of secretion. 
(3) Plastic bronchitis, in which the secretion is 
coagulated in the bronchi, occluding them by fibrous 
pings. A still further subdivision of the types of 
chronic bronchitis has been made upon the secondary 
changes in the lung, as: D. Bronchitis with spasm 
of the bronchi, spasmodic or asthmatic bronchitis. E. 
Bronchitis with distension of the alveoli, emphysema- 
tous bronchitis. E. Bronchitis with marked fibroid 
or interstitial changes. 

Physical Signs. Inspection. — A. There is no change 
in the size, shape or movements of the chest. B. 
Thorax early assumes emphysematous type. Move- 
ments at first are exaggerated, and are more frequent. 
Later, expansion interfered with. Expiratory dyspnoea. 
C. In simple serous bronchorrhoea the respiratory move- 
ments are similar to those of acute bronchitis ; in 
chronic purulent catarrh and simple putrid bronchitis, 
in the early stages, there is no change in the size or 
movements of the thorax. Later it assumes the 
emphysematous or fibroid type. Plastic bronchitis : 
extreme dyspnoea. Loss of expansion on inspiration 
especially marked over base of lung when localized to 
small portion of bronchial tract or limited motion over 
affected area. D. Thorax gradually assumes more or 
less the condition found in emphysema ; the movements 
of the chest are similar to those present during the 
attack of spasmodic asthma. E. Chest emphysema- 
tous in all respects. F. General retraction of the chest ; 
loss of expansion. 

Palpation. — A. Negative. B. Negative or vocal 
fremitus may be slightly diminished. C. Bronchor- 
rhoea; feeble vocal fremitus; rhonchi felt during acute 
paroxysmal attack. Plastic bronchitis; loss of vocal 



1 52 THE RESPIEA TOR V SYSTEM. 

fremitus over occluded tubes. I). Vocal fremitus fee- 
ble; rhonchi frequently present. E. Vocal fremitus 
feeble or absent. F. Enerease of vocal fremitus espe- 
cially marked over regions of large bronchi. 

Percussion. — Percussion note is unchanged in the 
milder types. When the lung lias undergone emphy- 
sematous changes the note is hyper-resonant. Fibroid 
and cirrhotic changes give more or less dullness, with 
woodeny quality. 

Auscultation. — A. Signs indefinite. Few large 
moist rales may be detected, especially if secretion is 
present. Over the large bronchi, the breath sounds may 
be slightly roughened in character. B. Dry catarrh ; 
respiratory murmur may be unchanged. 0. In (1) 
bronchorrhoea during the attack, large and small liquid 
rales and sibilant and sonorous rales may be present. 
Breath sounds obscured by loud noise of rales. After 
expulsion of mucus, the respiratory murmur may be 
normal. (2) In fetid bronchitis the rales are more or 
less constant. Breath sounds are feeble. (3) In plastic 
bronchitis over that portion of the lung supplied by 
occluded bronchus, there will be absence of all breath 
sounds. D. In spasmodic bronchitis, as the name 
implies, associated with the moist rales are the breath 
sounds and dry rales that characterize an acute 
asthmatic attack. E. In emphysematous bronchitis 
the breath sounds are feeble, especiallv the inspiratory 
sounds, the expiratory portion being prolonged, low 
pitched and usually attended with rales. F. In 
chronic bronchitis with fibroid change the inspiratory 
sound is feeble, but the expiratory portion is prolonged, 
high pitched and has a faint tubular character. 

Differential Diagnosis. — Chronic bronchitis is separated 
from the acute forms by the history of the attack and 
the presence of secondary changes in the lung. The 
various types of chronic bronchitis may be associated 
with pulmonary tuberculosis. 



DISEASES OF RESPIRATORY TRACT. 153 



BRONCHIECTASIS. 

Bronchiectasis is a distinct dilatation of the bronchial 
tubes. It may be limited to a portion of one lobe only, 
or may involve to a greater or less extent the bronchi of 
one or both lungs. Bronchiectasis is never a primary 
disease, but is secondary to some pathological change in 
the walls of the bronchi which alters or destroys their 
elasticity. The dilating force may be (a) increased 
pressure within the tube caused by coughing; (b) trac- 
tion on the walls, causing permanent enlargement of 
their calibre. This traction may be due to contraction 
of bands of fibrous tissue in the interlobular septa, 
especially when they are stretched from the bronchi out- 
ward to the pleura. The dilatation of the bronchi may 
be sacculated or cylindrical. 

The diseases with which bronchiectasis may be asso- 
ciated as a complication are broncho-pneumonia, capil- 
lary bronchitis with atelectasis, chronic bronchitis 
affecting the large and medium-sized tubes, emphysema, 
obstruction of the tubes from pressure from without, 
interstitial change in the lung, as occurs in chronic 
interstitial pneumonia (cirrhosis of the lung), in fibroid 
phthisis, and in pleurisy with retraction. 

Physical Signs. — The physical signs of bronchiec- 
tasis depend (1) upon the disease with which it is 
associated; (2) the nature of the dilatation, whether 
cylindrical or fusiform; (3) whether the air passes 
through the dilatation to structures beyond; (4) the 
localization and distribution of the dilatations; 1 (5) the 
proximity of the dilatation to the surface of the chest ; 
(G) the size of the tubes involved; (7) the condition of 
the cayity, whether full or empty. 

Inspection. — The chest conformation of bron- 
chiectasis is not typical. The shape and size of the 



1 One lung, 52 per cent.; both lungs, 48 percent. Of the unilateral cases the 
upper lobe was involved in 21 percent.; middle lobe, 3 percent.; lower lobe, 
32 per cent., and the entire Lung, 42 per cent. (Fowler.) 



1 54 THE EESPIE. ! TOE V 8 Y8TEM. 

thorax are determined by that of the disease to which it 
is secondary or with which it is associated. Three types 
occur — the emphysematous, the retracted and the com- 
bination of both, where retraction in one portion of 
the chest is compensated for by emphysematous expan- 
sion, at other portions. In the emphysematous type 
the upper portion of the chest, especially the supra- and 
infraclavicular spaces, are markedly distended, while the 
lower portion shows more or less retraction. Motion 
over the affected area is restricted according to the type 
of the disease and the condition of the surrounding 
lung. In mild cases, and when the disease is localized, 
motion may be but slightly impaired. When general 
or due to obstruction of the bronchi, the affected side 
will be more or less retracted. 

Palpation. — Vocal fremitus varies with the condi- 
tion of the lung surrounding the bronchiectatic dilata- 
tion. When involvement of the bronchi is associated 
with emphysematous dilatation of the surrounding tis- 
sue, vocal fremitus is normal or diminished. Vocal 
fremitus is absent in occlusion of the bronchi or filling 
of the cavities with secretion, and also when marked 
pleural thickening has occurred. It is increased when 
the lung is fibrous and the bronchial tubes are patent 
beyond the dilatation. 

Percussion. — Percussion note varies with the extent 
of the lesion, the condition of the surrounding lung, the 
nearness of the dilatation to the surface and the quantity 
of secretion in the cavities. As many of these factors 
are subject to frequent change, variation in the degree 
of resonance is an important diagnostic sign. When 
dilatation of the bronchi is slight, and it is surrounded 
by normal lung, the percussion sound may be normal. 
When marked emphysematous dilatation with relaxa- 
tion of the lung occurs, the sound will be hyper-resonant, 
with a somewhat tympanitic quality added, due to the 
dilatation of the bronchi. When the dilatation of the 
bronchus is large, and near enough to the surface to be 



DISEASES OF RESPIRATORY TRACT. L55 

influenced by the percussion, the sound will be tympa- 
nitic or amphoric, according to the size. There will be 
change in die unto according as the mouth is open or 
shut. When dilatation is surrounded by indurate* 1 
lung, the note is dull, high pitched, with peculiar 
tympanitic "boxy" or "boardy" quality. One of the 
distinctive features of the percussion sounds of bron- 
chiectasis is the localization of the change to the middle 
or lower third of the chest, especially over the back. 

Auscultation. — The most important sign is the 
blowing, hollow, but not tubular, sound when the dilata- 
tion is cylindrical, and a cavernous sound when the 
dilatation is sacculated. Both the inspiratory and 
expiratory breath sounds are interrupted and wavy, the 
blowing or cavernous quality being most marked just at 
the end of inspiration (veiled puff). Moist rales are 
present according to the amount and distribution of 
secretion in the bronchi and cavity. When the dilata- 
tions are cylindrical, the rales will have the character- 
istics of those heard in simple bronchitis of large and 
medium-sized tubes. But the size of the rales is larger 
than would he found if the tubes in that region were of 
normal calibre. In sacculated dilation the rales are 
larger, more gurgling, with an occasional croaking, 
sonorous rale. When the dilatation is surrounded by 
fibrous lung, the rales have a ringing or metallic quality. 
The occurrence of acute general bronchitis will change 
the character of the physical signs present over the 
cavity according as the bronchi are narrowed by inflam- 
matory swelling or cavity filled with liquid secretion. 
With the subsidence of acute bronchitis, instead of the 
breath sounds returning to normal, the characteristic 
sounds of dilatation are heard. Vocal resonance over 
the cavity and whispered cavernous or amphoric breath 
3ounds may be heard, according to the size and condition 
of the cavity and the surrounding lung. 

Differential Diagnosis. — Bronchiectasis must be differ- 
entiated from other diseases of the lung in which cavity 



1 5 G THE RESPIB. 1 TOE ) ' 8 1 r 8 TEM. 

formation occurs. The character of the physical signs 
heard over the site 1 of dilatation in bronchiectasis is not 
pathognomonic, and a diagnosis of the nature 1 of the 
cavity can only be readied by exclusion. 

Pulmonary Tuberculosis. — Pulmonary tuberculosis is 
the most frequent cause of the cavities found in the 
lung. 

Location. — Non-tubercular, solitary bronchiectatic 
cavities rarely involve the apices. It is most common 
at the base, but may involve the middle or lower third 
of the lung. Tuberculosis is especially likely to involve 
one or both apices primarily, extending to the middle 
and lower portions. In bronchiectasis the changes in 
the portion of the lung involved are more or less 
uniform. In phthisis limited portions of the lung may 
show the different stages of the diseases. 

Inspection. — In bronchiectasis the retraction is most 
marked over the lower portion of chest ; the upper por- 
tion may be normal or show in supra- and infraclavicu- 
lar spaces emphysematous dilatation. In tuberculosis 
the retraction is most marked in the upper portion of 
the lung; the supra- and infraclavicular spaces are 
depressed. In bronchiectasis the patient is fairly well 
nourished, and there is more or less duskiness of the 
skin, congestion of the mucous membrane, fullness about 
the lips and nose and the jugulars are distended. The 
tuberculous patient is emaciated, the mucous membrane 
and skin pale and anaemic and there is no distension 
of jugulars. In bronchiectasis the heart is displaced 
horizontally towards the diseased side ; epigastric pulsa- 
tions are present. In tuberculosis the heart is displaced 
upwards and obliquely, and without epigastric pulsation 
except when it involves the base of the lung secondary 
to changes in the pleura. 

Palpatiox. — In bronchiectasis vocal fremitus may 
be diminished, except when marked fibroid induration 
is the cause of the dilated bronchi. In tuberculosis vocal 
fremitus is generally increased in proportion to the 
amount of consolidated lung tissue around the cavity. 



DISEASES OF RESPIRATORY TRACT. 157 

Percussion. — Bronchiectasis : The supraclavicular 
region is rarely dull ; its note is generally hyper-resonant 
or emphysematous. Dullness most frequently present 
over lower portion of ehest. Tuberculosis: Dullness 
at the apex, becoming more intense as consolidation 
advances. Cavernous, amphoric or cracked-pot percus- 
sion always follows a first stage of dullness. 

Auscultation. — Bronchiectasis: The blowing, hol- 
low sound of cylindrical dilatation and the cavernous 
tubular sound of the sacculated form are unattended by 
any signs of pulmonary consolidation. Normal breath- 
ing sounds may be heard between the areas of cavern- 
ous breathing. In tuberculosis the sound is cavernous 
or amphoric. Bronchial breathing is heard over sur- 
rounding lung. In bronchiectasis the signs indicate 
that the cavities are of uniform size. In phthisis the 
cavities are rarely uniform. In bronchiectasis the size 
of the cavities remains stationary. In phthisis the 
cavities gradually enlarge, with associated signs of 
softening. 

General Bronchitis and Fetid Bronchorrhcea. — Bronchiec- 
tasis is distinguished from general bronchitis by absence 
of fetor ; from simple fetid bronchitis or bronchorrhoea 
the differential- diagnosis is often extremely difficult. 

The following signs are most important : Hollow, 
blowing or cavernous or amphoric breath sounds, accord- 
ing to the type of cavity. In general bronchitis vesic- 
ular murmur is present, but diminished or feeble ; 
cavernous breathing not present. Size of rales has an 
important significance. In bronchiectasis over cavity 
there are large moist rales, mucous clicks and gurgles ; 
they are larger than could occur if the lumen of bronchi 
in that region was normal. In chronic bronchitis the 
size of the rale corresponds to the normal size of the 
tube. 

Gangrene and Pulmonary Abscesses. — In pulmonary 
gangrene and pulmonary abscess there may be one or 
more cavities. When single, they generally follow some 



158 THE RESPIRATOR V SYSTEM. 

inflammatory condition of the lung or adjacent viscera. 
The signs of cavity formation are limited to a small 
portion of the lung, and are more likely to he close to the 
surface. The patient is acutely ill. Respirations are 
rapid and motion markedly interfered with over affected 
area. Pulse is rapid, feehle and dicrotic. Before the 
stage of excavation there is dullness on percussion ; vocal 
fremitus is increased; there is hronchial breathing. 
With the production of the cavity, the hollow, blowing, 
cavernous or amphoric quality of breath sounds will be 
associated with the signs of more or less complete con- 
solidation. When the cavities are multiple, they are 
nearer to the surface of the lung than in bronchiectasis ; 
there is early involvement of the pleura over affected 
area. 

In bronchiectasis the patient is usually well nour- 
ished, and does not give the impression of being acutely 
sick. Changes in respiratory movement are most 
marked over lower third of lung. 

Microscopical Examination. — Presence of elastic 
fibres in the sputum is diagnostic of the destructive 
process of gangrene and abscess. They are absent in 
simple bronchiectasis. 

Localized Empyema Opening into a Bronchus. — Local- 
ized empyema opening into a bronchus, with localized 
pyo-pneumo-thorax, may simulate a bronchiectatic 
cavity, and is differentiated by the following: The 
enlargement of the chest is localized at the site of the 
lesion. The percussion note is tympanitic when cavity 
is empty. If it contains fluid, there will be zone of 
flatness, which changes with the position of the patient. 
Lung fistula sound is present rather than the hollow, 
blowing or cavernous sound of bronchiectasis. 

ACUTE CONGESTION OF THE LUNG. 

Active hyperemia of the lung may be general or local. 
It depends on (a) cardiac overaction due to muscular 



DISEASES OF RESPIRATORY TRACT, 159 

exertion, cardiac stimulants, aervous or emotional 
causes; (t>) irritation of the respiratory tract duo bo 
inhalation of steam, extremely cold air or oilier irri- 
tants; (c) determination of Mood to the lungs by chill- 
ing of the surface of the body or during the chill of 
acute diseases, especially malaria; (d) it occurs during 
onset of all inflammatory diseases of the lung. 

Physical Signs. — The physical signs will vary accord- 
ing to the degree of congestion. The distension of the 
blood-vessels is especially marked in the alveolar walls, 
causing the pulmonary tissue to be increased in amount 
and less elastic, with corresponding diminution in the 
amount of tidal and residual air. 

Inspection. — Dyspnoea, with respiration more rapid 
than normal. 

Palpatio^. — Yocal fremitus unaltered or slightly 
increased. 

Percussion. — Resonance slightly impaired ; pitch 
somewhat raised; change in percussion note not suffi- 
cient to give well-marked dullness. 

Auscultation. — The respiratory murmur has less 
of the vesicular quality than normal; inspiration is 
harsher and slightly higher pitched; expiration is pro- 
longed, higher pitched than inspiration, with a blowing 
quality. When localized, the above changes in the 
physical signs are more noticeable by comparison with 
the surrounding normal lung. 

PASSIVE CONGESTION OF THE LUNG. 

Passive hypersemia of the lung is caused by interfer- 
ence with pulmonary circulation, due to (a) organic 
lesions at the valvular orifices or to pressure of inter- 
thoracic tumors; (b) to insufficiency of cardiac power, 
dependent upon myocardial disease or secondary to 
adynamic conditions, as typhoid fever, anaemia, etc. 
Feebleness of respiratory movements favors stasis at 
the borders of the lung, while gravity causes the circula- 



1 GO THE BESPI& I TOR Y 8 YSTEM. 

tion to be weakest in the most dependent portions (hypo- 
static congestion), which varies with the posture of the 
patient. 

Long continuance of passive congestion causes exuda- 
tion of serum into the interstitial tissue (hypostatic 
pneumonia), into the alveoli, infundibula and bronchi 
(pulmonary oedema), and red-blood cells and connective 
tissue elements into the stroma of lung (brown indura- 
tion). 

Physical Signs. Inspection. — Dyspnoea; respiratory 
movements most marked over upper portion of chest ; 
loss of motion over base of lungs ; slight cyanosis, espe- 
cially during sleep and on exertion. Patient gradually 
assumes the sitting posture. 

Palpation. — Vocal fremitus normal over upper por- 
tion of lung; diminished along edge of lung and over 
base in simple, passive congestion. When secondary 
changes (induration) occur, vocal fremitus is increased. 

Percussion. — Upper portion of chest normal or 
hyper-resonant ; over base, slight dullness, most marked 
over right side below angle of scapula. Secondary 
changes in the lung causes the dullness to be replaced by 
flatness. 

Auscultation. — Over upper portion of chest, the 
breath sounds may be normal; or with inspiration 
harsher and expiration blowing and prolonged. Over 
the lower portion of the chest, the vesicular murmur is 
feeble or absent. When induration occurs, the breath 
sounds have a bronchial quality. Pales are present in 
oedema. 

In the early stage the physical signs are bilateral ; 
later they become more intense, according to the posture 
of the patient, over certain portions of the lung. 

PULMONARY (EDEMA. 

Pulmonary oedema is never a primary condition, but 
always secondary to (a) acute inflammation of the lung, 



DISEASES OF RESP1RAT0&F TftACT. 161 

(b ) passive congestion, (c) or is part of a general 
oedema. The oedema will be local or general, according 

to the cause, and its distribution will be influenced by 
the same factors that were mentioned under passive 

congestion. 

Physical Signs. Inspection. — The changes in size, 
shape and motion will depend upon the condition to 
which the oedema is secondary. Filling of the alveoli 
at the most dependent portion causes loss of motion, 
with compensation elsewhere. 

Palpation. — Vocal fremitus is diminished or absent 
over the lower portion of the chest. Rhonchi may be 
detected when fluid is present in the larger tubes. 

Percussion. — Dullness in the early stage over the 
base of the lung. As the air spaces become filled with 
fluid, dullness becomes more intense, and may be 
replaced by flatness. The line of dullness gradually 
extends upward with increased severity of the condi- 
tion. 

Auscultation. — The distinctive physical sign of 
pulmonary oedema is the presence of fine, crepitating, 
moist rales. In mild cases these are heard over the 
most dependent portions and along the borders, while 
over the rest of the lungs the breath sounds may be 
normal. As the oedema becomes more intense and 
involves the bronchi, rales of larger size and more 
bubbling are also heard. 

LOBULAR PNEUMONIA. 

Synonyms. — Broncho-pneumonia, disseminated ca- 
tarrhal pneumonia, pulmonary catarrh. 

Lobular pneumonia is characterized by a filling of the 
alveoli by inflammatory products, which differ from 
those of lobar pneumonia in containing less of the fibrin 
factors of the blood and more of the elements drawn 
from the lining membrane of the alveoli and bronchi. 

The pathological changes of lobular pneumonia may 
11 



162 THE RESPIRATOR V SYSTEM. 

be due to a variety of causes : (a) Capillary bronchitis, 
(b) acute pulmonary catarrh of whooping cough and 

other infectious diseases; (c) passive or hypostatic con- 
gestion, (d) pulmonary infarction, (r) diffused tuber- 
cular infection. (See Pulmonary Tuberculosis.) 

The distribution of the areas affected by catarrhal 
pneumonia will vary according to the nature of the 
cause; the type is determined by the physical signs. 
The affected lobules may be widely and fairly evenly 
scattered through both lungs, and separated by normal, 
emphysematous or collapsed lobules, giving (A) the dis- 
seminated type of lobular pneumonia. Usually a 
number of adjacent lobules are involved, and produce 
well-marked patches of consolidation in different por- 
tions of the lung. (B) The confluent type is due to the 
coalescence of these patches, causing one or more lobes 
to be almost completely consolidated, producing a condi- 
tion which gives physical signs almost identical with 
those of lobar or croupous pneumonia. 

Physical Signs. A. Disseminated Lobular Pneumonia. 
— The physical signs of this form have been described 
under D. Acute Bronchitis. 

B. Confluent Lobular Pneumonia. — The physical signs 
differ from those of the disseminated type, as follows : 

Inspection. — Dyspnoea is more markedly obstructive 
during inspiration. As both lungs are not equally 
involved, deficient expansion is more marked over one 
side of the thorax. When due to passive or hypostatic 
congestion, loss of motion is most marked over the base 
or dependent portions. 

Palpation. — Vocal fremitus may be increased when 
the areas of consolidation are close to the surface. When 
they are separated from the surface by emphysematous 
lung or surrounded by collapsed lobules, vocal fremitus 
may be normal or diminished. 

Percussion. — In the early stage percussion may be 
normal. When surrounded by collapsed lung, the per- 
cussion note is dull, but of a tympanitic quality. With 



Dlsl\ \ sFs OF UESPlRu I TOR V TIL WT. 1 63 

increase in consolidation, the resonance is diminished, 
the note becomining dull and high pitched. 

Auscultation. — The change in the breath sound will 
vary with the amount of pulmonary consolidation and 
its relation to the surface of the chest. When the con- 
solidated area is deep seated or surrounded by normal, 
emphysematous or collapsed lung, the bronchial quality 
will not be heard, or it will be faintly detected only at 
the end of expiration (see Fig. 24). The nearer the 
pneumonic patch approaches the surface, the more dis- 
tinctly will the bronchial breathing be heard. The 
rales heard over the consolidated part differ from those 
heard in bronchitis, in being more uniform in size ; their 
number is fairly constant, and the quality is clearer, 
higher pitched and more definitely ringing, resembling 
the crepitant and subcrepitant rales of lobar pneumonia. 

Differential Diagnosis. Pulmoriary Collapse (Atalectasis.) 
— Pulmonary collapse and lobular consolidation are 
both common in extensive bronchitis of the smaller 
tubes, and are usually associated. The physical signs 
will vary according as one or the other condition is 
predominant. 

Ixspectioist. — In both conditions motion is restricted, 
especially over the lower portion of the chest. 

Palpatiox. — In consolidation vocal fremitus is nor- 
mal or slightly increased. In pulmonary collapse vocal 
fremitus is diminished or absent. 

Percussion. — In pulmonary consolidation the per- 
cussion note is dull. In pulmonary collapse there is 
diminished resonance, with tympanitic quality. 

Auscultation. — In consolidation the breath sounds 
are more or less bronchial in character. In pulmonary 
collapse the breath sounds are feeble or absent. Vocal 
resonance, in consolidation increased; in collapse, feeble 
or muffled. 

Acute Disseminated Tuberculosis. — Differential diag- 
nosis between acute disseminated tuberculosis with soft- 
ening and disseminated lobar pneumonia is extremely 



164 THE BJE8PIEA TOE V SYSTEM. 

difficult. Physical signs may be identical, the location 
of the two conditions being frequently the only dis- 
tinctive point. Tuberculosis affects especially the 
apices, while lobular pneumonia involves the lower 
lobes, especially the base. 

Acute miliary tuberculosis without softening is dif- 
ferentiated from broncho-pneumonia in that it involves 
the apex, and rales are not common. 

Broncho-pneumonia involves the base, and is attended 
with rales. 

Lobar Pneumonia. — Lobular pneumonia may be so 
extensive as to consolidate more or less completely an 
entire lobe. Lobular pneumonia, even w 7 hen more or 
less lobar in character, does not present the uniform 
consolidation that occurs in lobar pneumonia, nor is it 
limited to one lobe or to one lung. In the second stage 
of lobar pneumonia over the affected portion of the lung 
the breath sounds are usually clear and unattended with 
rales. 



LOBAR PNEUMONIA. 

In lobar or croupous pneumonia the alveoli and 
smaller bronchi are filled with an exudate composed of 
coagulated fibrin and cellular elements. During the 
course of the disease the pathological changes that occur 
pass through three definite stages. 

1. Stage of Engorgement. — The lungs are intensely 
congested, especially in the affected lobe, whose dis- 
tended blood-vessels interfere with its expansion and 
elasticity; the pulmonary tension is altered, and there 
is slight enlargement of the lobe. There is more or 
less liquid secretion in the alveoli and bronchioles, and 
also oedema of the subpleural and pleural tissues. There 
may also be a layer of plastic material on the free sur- 
face of the pleura. This stage may last from a few 
hours to three or four days. 

2. Stage of Red Hepatization, or Consolidation. — In this 
stage there is distension of the alveoli and bronchioles, 



DISEASES OF RESPIRATORY TRACT. 165 

with serum, leucocytes and red-blood corpuscles. The 
serum coagulates and holds in its meshes of fibrilated 
fibrin the corpuscular elements. The consolidated por- 
tion is airless and "in a state of immovable expansion 
more densely solidified than it could be by any artificial 
injection with coagulable fluid." (Powell.) 

The pleura over the consolidated portion is covered 
with a layer of the same coagulated exudate. In addi- 
tion, the pleural sac may contain fluid serum, which may 
be clear, turbid, blood-stained or purulent. Complete 
consolidation of the affected lobe may occur in a few 
hours, or, beginning in a circumscribed portion, it may 
be days before it extends throughout the entire lobe ; or 
it may remain limited to a portion of the lobe onlv. 
This stage lasts usually from five to seven days, termi- 
nating with the crisis. 

3. State of Gray Hepatization, or Resolution. — The 
changes that take place during the stages of engorgement 
and consolidation are fairly constant and rapid. Those 
that occur during the third stage may be variable. At 
the beginning of the stage of gray hepatization the bulk 
of the lung is greater than in that of red hepatization, 
but it is less firm. The solid coagulum in the alveoli 
undergoes liquefaction ; air again enters the alveoli, pass- 
ing through the liquid exudate, giving rise to large moist 
rales that are named rale redux. The third stage of 
pneumonia may terminate in (a) resolution. The con- 
tents of the alveoli are removed by absorption and 
expectoration; the lung regains its resiliency and 
returns to normal condition. In the majority of cases 
perfect resolution and recovery occurs. 

(b) Purulent Infiltration and Abscess of the Lung. — 
In this condition the coagulated fibrin liquifies, but, 
instead of fatty degeneration and absorption of the cor- 
puscular elements, a suppurative inflammatory process 
continues ; there is destruction of the lung tissue and the 
formation of cavities of varying sizes. 

(c) Gangrene results from failure of nutritive circu- 



166 THE RESPIRATORY SYSTEM. 

lation, either through thrombosis of the large vessels or 
capillary stasis. 

(d) Unresolved or Chronic Pneumonia. — In this con- 
dition the changes that ordinarily occur with the crisis 
are absent. There is a proliferation of new cells in the 
tissues of the lung and also in the alveoli. These organ- 
izes into new tissue, and there is a gradual development 
of fibrous tissue in the alveoli. 

Physical Signs. — The physical signs of pneumonia have 
been divided into three stages, corresponding to the 
pathological changes in the lung. It must be constantly 
borne in mind that these pathological divisions are 
largely arbitrary, and that as the transition of one stage 
into the other may be rapid or gradual, so the physical 
signs of one stage merge into those of the succeeding 
stage. 

Inspection. — First Stage. Patient lies on the 
affected side; circumscribed flush (pneumonic spot) 
over one or both malar bones; repiration rapid, 25 to 
40, panting in character, especially during expiration. 
Motion on affected side slightly restricted. When the 
pleura is not involved, the movements of the two sides 
may be equal. When pain (pleurisy) is present, 
motion is less on the affected side than on the opposite ; 
inspiration is either catching or restrained ; expiration is 
slow. Movements of the opposite side are exaggerated. 

Second Stage. Face dusky; marked movements of 
the nares ; breathing rapid and panting. Slight enlarge- 
ment of the affected side of the chest. Motion on the 
affected side diminished, with compensatory movement 
on the opposite side. Breathing will be costal or 
abdominal, according as the upper or lower lobes 
are involved. Involvement of the diaphragm (dia- 
phragmatic pleurisy) causes absence of abdominal 
breathing. 

Third Stage. With the absorption of the exudate, 
movements of the affected side gradually return to 
normal. 



DISEASES OF RESPIRATORY TRACT. 107 

-First Stage. During the early stage 
of engorgement vocal fremitus is normal <>r slightly 
diminished. As consolidation occurs, it gradually 
increases in intensity. 

Second Stage. When consolidation of the lung is 
complete, vocal fremitus is greatly increased. In cen- 
tral pneumonia vocal fremitus may be but slightly 
increased. It is diminished in marked thickening of 
the pleura, and absent when effusion occurs in the 
pleural sac, and also when the large bronchi leading 
to consolidated portion is blocked. Friction fremitus 
may be felt over the affected part in the earlier stages of 
consolidation, while movement of the lung is still 
possible. 

Third Stage. There is gradual diminution of vocal 
fremitus with return to the normal. During the early 
stage of resolution, blocking of the bronchus is most 
likely to occur, with a temporary absence of vocal 
fremitus. After paroxysms of coughing vocal fremitus 
may return. Absence of vocal fremitus after the 
removal of exudate from the alveoli is due to exudation 
on the pleura or filling of the pleural sac. 

PePvCussiox. — First Stage. Percussion note at first 
may show no change. As congestion increases, the 
intensity diminishes ; it is shorter in duration, higher 
pitched and resonant, but with a slight tympanitic 
quality. The dullness of consolidation is most apt to 
appear first just beneath the angle of the scapula and 
to develop towards the axillary line. As air in the 
alveoli is replaced by the solid exudate, the note becomes 
duller, higher pitched and less resonant, until complete 
consolidation. 

Second Stage. The percussion note is dull and high 
pitched, but even in complete consolidation resonance is 
present in a very slight degree. The sound is flat if 
pneumonia is complicated by extensive pleuritic 
changes. 

When consolidation of the lobe is not complete, the 



1 68 THE RESPIB. I TOR Y SYSTEM. 

air-containing, but relaxed, lobules scattered through the 
consolidated portion cause the percussion note to have 
a dull, tympanitic or tubular quality. When the pneu- 
monia is central and air-containing lung is interposed 
between the chest wall and the consolidated portion, the 
character of the percussion note will depend upon the 
condition of the interposed lung, (a) When the lung is 
in a state of compensatory emphysema and tension is 
increased, the percussion note gives increased resonance. 
(b) When the lung is relaxed, the percussion note is 
dull, with tympanitic or cavernous quality. Percussion 
dullness is especially apt to be absent in children and in 
old persons, due to the elasticity of the chest wall in 
children and the emphysematous condition of the lung, 
associated with rigid thorax, in the aged. 

The normal boundaries of the lobes are changed, so 
that when the lower lobe is involved the dullness extends 
higher than the normal outline, and may be detected 
almost to the upper portion of the scapula. When the 
upper lobe is involved, the dullness is most marked 
anteriorly. Enlargement of the consolidated portion 
allows of relaxation of the unaffected portions of the 
lung on the same side, over which a peculiar tympanitic 
resonance is obtained — Skoda's resonance. Percussion 
over the opposite lung shows exaggerated percussion 
note, due to compensatory emphysema. 

Third Stage. As the removal of the exudate con- 
tinues and the alveoli again contain air, the percussion 
sound becomes more resonant. The pulmonary tissue 
does not at once regain its normal elasticity, and fre- 
quently with the return of resonance the sound has a 
more or less tympanitic quality and is low pitched, on 
account of the relaxation of the lung*. Dullness may 
be continued after resolution is well advanced, owing to 
the presence of pleural exudate. Flatness over the base 
of the lung occurs in cases of unabsorbed effusion in the 
pleura or the occurrence of empyema. It was noted 
above that lobar pneumonia in children is frequently 



DISEASES OF RESPIRATORY TRACT. 109 

unattended with marked dullness. The presence of 
well-marked dullness, with increased resistance over the 
lower portion of the lung, is usually due to the occur- 
rence of acute empyemia during the course of a pneu- 
monia. 

Auscultation. — First Stage. In the earliest stage 
of engorgement the breath sounds are weaker than 
normal over the affected portion. Over adjacent por- 
tions the breath sounds are slightly exaggerated; later, 
as the engorgement increases, the breath sounds become 
harsher, especially marked during expiration. As the 
exudation fills the alveoli, the inspiratory portion of the 
breath sound loses its vesicular element, has a faint 
blowing quality, and the pitch becomes higher. The 
expiratory portion is at first slightly prolonged, higher 
pitched, with a distinct bronchial character. As the 
consolidation becomes more marked, there is a gradual 
disappearance of the normal vesicular murmur and an 
increase in the intensity of the bronchial breathing. 

The crepitant rales (rale indux), which has been 
considered by some authors as characteristic of this 
stage of pneumonia, may be present before percussion 
dullness or the occurrence of the bronchial type of 
breathing. The crepitant rale is not always present. 
It may be absent (a) when the consolidation is central 
and there is no pleural involvement ; (b) when complete 
consolidation occurs very rapidly; ( c) in secondary 
pneumonia. When pneumonia is superadded to acute 
bronchitis, large and small moist rales may be present 
and mask the crepitant rale and the early changes in the 
breath sounds. The crepitant rale, when present, is of 
important diagnostic significance. 

Second Stage. Bronchial breathing during the 
second stage is present in proportion to the degree of 
consolidation. As the alveoli becomes filled, the breath- 
ing passes from a stage of high-pitched, prolonged 
expiration, broncho-vesicular, to pure tubular and 
laryngeal breathing. The bronchial, tubular and 



170 THE BESPIBATOEY SYSTEM. 

tracheal breathing that is present in pneumonia differs 
from that heard over the bronchi, trachea and larynx in 
the normal lung. It is higher pitched; expiration is 

more prolonged, and the tubular element has a peculiar, 
distinct, "audible" quality, which is a striking feature 
of the sound. Although it may not be very loud, this 
quality of the sound is easily detected when present 
This distinctive quality of the breath sound in pneu- 
monia is due to the resonating influence of the dense 
consolidated lung on the vibrations brought to it by the 
walls of the bronchi. In central pneumonia the inter- 
posed unconsolidated lung causes the breath sounds to 
have a combined distinct bronchial breathing, associated 
with normal vesicular murmur. The bronchial element 
in these cases is especially marked during expiration. 
When the amount of consolidation is slight and situated 
deep in the lung, the bronchial sound may not be 
detected as such, but a high-pitched, blowing sound 
may be heard after the expiratory sound of the normal 
lung has ceased. In cases of central pneumonia, 
increased vocal resonance (bronchophony) may be the 
only sign present. Plugging of a large bronchus causes 
the bronchial breathing to be absent. This is especially 
apt to occur in the massive type of pneumonia. Thick 
exudation upon the pleura or effusions into the pleural 
cavity gives a weakening or absence of the bronchial 
sounds. Effusions into the pleural cavity, especially 
where they occur before the stage of complete con- 
solidation^ give a type of breathing that is similar to 
cavernous breathing. In pneumonia affecting the 
upper lobes of the lung, feebleness or absence of bron- 
chial breathing may occur without blocking of the 
bronchus or the interference of thick pleural exudate. 
Over the unaffected portion of the same side, the respira- 
tory sounds may be feeble or exaggerated, according as 
the lung is relaxed or is in a state of compensatory . 
emphysema. Over the opposite lung the breath sounds 
are exaggerated. Frequently bronchial breath sounds 



DISEASES OF RESPIRATORY TRACT. 171 

may be transmitted to the opposite side, suggesting the 
occurrence of (loul)lo pneumonia. Vocal resonance is 
increased in intensity in proportion to the degree of 
consolidation, and corresponds to the various changes 
that occur in the bronchial breathing'. Pectoriloquy 
is present in complete consolidation. In central pneu- 
monia, when uninvolved overlying lung masks the 
physical signs, increase in vocal resonance may be the 
only diagnostic* symptom present; it should always be 
sought for in doubtful cases, especially in the aged. 

Third Stage. The earliest indication of change in 
the consolidated lung is that the peculiar, clear, "audi- 
ble" character of the bronchial breathing of the 
second stage is lost. The breath sounds become bron- 
chial, and their vibratory quality gradually disappears. 
With these changes in the bronchial sounds, air again 
enters the bronchioles and alveoli, and medium-sized 
rales (rale redux) are heard with inspiration and 
expiration. As the alveoli become free of the exudate, 
the moist rales diminish in number and finally dis- 
appear. The vesicular quality returns as the bronchial 
is lost. 

As the lung does not at once regain its normal 
elasticity, the expiratory sound may for a variable time 
be slightly prolonged and low pitched. In chronic 
unresolved pneumonia the signs of the secondary stage 
persist for a long time, and are gradually replaced by 
those of chronic interstitial pneumonia. When the 
pneumonic area undergoes purulent infiltration, the 
rale redux is associated with or displaced by larger 
liquid rales ; the bronchial element of sound persists, 
and later, with the destruction of lung tissue, cavernous 
breath sounds are present. 

Vocal Resonance. — With the beginning of the third 
stage, pectoriloquy of the second stage is replaced by 
bronchophony, which gradually diminishes in intensity 
until it becomes exaggerated resonance. With the com- 
pletion of resolution, the voice sounds return to the 
normal. 



1 < V THE RESPJEATOBY SYSTEM. 

Differential Diagnosis. Acute Pulmonary Congestion.— 
During the early part of the first stage of pneumonia 
the harsh respiratory murmur over the lung is due to 
acute congestion of the entire respiratory tract. As the 
localization of the congestion occurs in the lobe that is 
to he affected, there Avill be a gradual increase in the 
harshness of the respiratory murmur in comparison 
with the rest of the lung. 

Pleurisy with Effusion. — During the stages of consoli- 
dation and resolution, pneumonia may be confounded 
with effusion into the pleural cavity. It is especially 
important that these two conditions be differentiated, 
on account of the frequency with which empyema fol- 
lows pneumonia, especially in children. 

Inspection. — In pneumonia the size of the chest is 
only slightly increased ; the intercostal spaces persist, 
not being flattened or bulged; motion of the affected 
side is limited ; of the opposite, slightly increased. In 
effusion into the pleura the enlargement of the affected 
side is marked; there is flattening or bulging of the 
intercostal spaces. The motion over lower portion of 
the chest is absent. Position of the heart: In pneu- 
monia the apex beat is in a normal position. In 
effusions the heart is displaced. Location of the apex 
beat of the heart is one of the most important signs in 
separating the two conditions. 

Palpation. — In pneumonia the vocal fremitus is 
markedly increased, except when the bronchus is 
plugged. In effusion vocal fremitus is absent, and is 
only detected when adhesions are present. In pneu- 
monia the diaphragm is not displaced downwards, and 
there is no change in the position of the abdominal 
organs. In effusion there is marked displacement of 
the diaphragm; the liver or spleen are palpable below 
the free border of the ribs. 

Percussion. — In pneumonia the note is dull, but 
still resonant; it is not flat. In effusion, note flat or 
toneless. In pneumonia the area of percussion dullness 



DISEASES OF RESPIRATORY TRACT. 173 

follows the anatomical division of the lung. In effusion 
it follows a curved line, being highest in the axilla. 
Skoda's resonance may be present in both conditions. 

Auscultation. — In pneumonia the breath sounds 
over area of dullness are bronchial or tubular in char- 
acter. The sound gives the impression of being pro- 
duced close to the surface. In effusion the breath 
sounds are absent over the lower portion of flatness; 
may be present at the upper level of the fluid, and differ 
from those of pneumonia in lacking clearness and being 
more or less distant from the surface. In pneumonia 
during the stage of resolution, rales are present. In 
effusion, liquid rales are not detected ; friction rales may 
occasionally be heard. 

Vocal Resonance. — In pneumonia, bronchophony or 
pectoriloquy is present. In effusion over lower por- 
tion of thorax, the voice sounds distant from the ear. 
Over the upper portion of the fluid pectoriloquy of a 
peculiar nasal character is heard (segophony). 

Hemorrhagic Infarction. — In hemorrhagic infarction 
the consolidation of the lung is due to the presence in 
the alveoli of the affected area of coagulated blood, so 
that the physical condition of that portion of the lung 
involved by hemorrhagic infarction is identical with 
that of a localized lobar pneumonia. Differential diag- 
nosis is based on the position and distribution of the 
consolidation and the presence of valvular disease of the 
heart. In pneumonia the entire lobe is usually 
involved. Hemorrhagic infarction is localized, and is 
generally most apt to occur at the lower portion of a 
lobe and along its border. In pneumonia, unless com- 
plicated by organic cardiac disease, there are no adventi- 
tious heart sounds. Hemorrhagic infarction is generally 
associated with the physical signs of valvular lesion of 
the heart. The dyspnoea in pneumonia is panting ; the 
patient lies upon the affected side or more or less flat 
upon the back. In hemorrhagic infarction the patient 
assumes the position of orthopncea during the early por- 
tion of the attack. 



174- TIIK UESPIRA TOR V SYSTEM. 

Collapse of the Lung. — When this condition occurs in 
children, or when it affects the entire lobe, differential 
diagnosis may be very difficult. On inspection, in 
pneumonia, there is slight enlargement of the side. In 
collapse, retraction of the side occurs. In pneumonia 
there is increased vocal fremitus. In collapse, fremitus 
is diminished or absent. 

In pneumonia there is dullness on percussion. In 
collapse the resonance is slightly impaired and asso- 
ciated with marked tympanitic quality. 

In pneumonia there is well-defined bronchial breath- 
ing. In collapse the breath sounds are feeble; may 
have slight bronchial character, but are indistinct and 
distant from the ear. Pneumonia, during first and 
third stages adventitious sounds present. Collapse, 
these signs may be absent. 

CHRONIC INTERSTITIAL PNEUMONIA. 

Synonyms. — Cirrhosis of the lung. Fibroid phthisis. 

The distinctive pathological change in this type of 
pulmonary disease is the increase in the fibrous struct- 
ures of the lung. This overgrowth of connective tissue 
may be limited to the peribronchial tissue of the larger 
or medium-sized tubes. It may affect the interlobular 
septa, extending into the interlobular wall. In other 
cases it primarily involves the walls of the alveoli 
themselves, while in others it starts in the subpleural 
and pleural tissues and gradually extends inwards. It 
is rare to find fibroid induration limited to the different 
tracts above mentioned, although it may have its origin 
in one or the other of them. 

The effect of increase of fibrous tissue is (a) to 
increase the solid structures of the lung, (b) Accord- 
ing to the law of fibrous tissue, contraction takes place. 
(c) The induration of the tissue and the thickening of 
the walls of the alveoli interfere with the elasticity of 
the lung, and causes more or less impairment of the pul- 
monary function, (d) Following the contraction, there 



DISEASES OF RESPIRATORY TRACT. 175 

is more or less atrophy of the alveolar walls, resulting 
in emphysematous dilatation, or disappearance of the 
walls, and coalescence of adjacent alveoli. Bronchiec- 
tasis of varying degree is also present. 

Three types of pulmonary fibrosis can he recognized 
by physical signs: (1) The massive or lohar type; 
(2) the broncho-pneumonic type; (3) the disseminated 
reticular or diffuse form. The type of the disease 
corresponds more or less closely to the etiological factors. 

(1) Lobar pneumonia and the confluent type of 
broncho-pneumonia with collapse are often the origin 
of the massive or lobar type. Pleurisy with effusion, 
in which there has been extensive changes in the pul- 
monary subpleural tissue and long retention of fluid in 
the sac, causing more or less pulmonary collapse, is 
frequently followed by a lobar type, in which the 
primary changes are at the surface of the lung, crippling 
its respiratory function, and followed by retention of 
secretion within the alveoli, secondary broncho-pneu- 
monia, and subsequent diffuse fibrosis. The occlusion 
of a large bronchus by foreign bodies or by pressure, 
as of aneurism, causes the tissue beyond the obstruc- 
tion to collapse more or less. There is retention of 
inflammatory exudates, and the subsequent development 
of fibroid tissue. 

(2) The broncho-pneumonic type may be induced by 
those conditions which cause diffuse capillary bronchitis 
or broncho-pneumonia. The broncho-pneumonic type, 
when localized at the apices, is especially prone to occur 
as a part of the pathology of pulmonary tuberculosis, 
and is to a large extent a conservative process. It may 
occur either at the beginning of the disease, may follow 
on acute secondary inflammation or may be cicatricial 
when there has been cavity formation. 

(3) The disseminated type is generally dependent 
upon chronic bronchial irritation which may follow 
simple bronchitis, or may be due to the mechanical 
irritation in the so-called dust disease, or pneumono- 



1 76 THE EE8PIB. I TOR F 8 YSTEM. 

koniosis. Two forms of diffuse fibrosis are recognized 
by physical signs : 1. The emphysematous form, in 
which the fibroid tissue of the peribronchial and inter- 
lobular portions of the lung are especially involved and 
there is associated dilatation of the alveoli. 2. The 
contracted form, in which the alveolar walls and the 
subpleural tissue are especially involved. In this there 
is marked loss of the expansile tissue of the lung. 

Physical Signs. Ikspectioj*. — In the localized fibro- 
sis of the lobar and broncho-pneumonic types there is 
marked retraction of the chest over the seat of the 
disease, the extent being in proportion to the amount 
of lung tissue involved. Retraction of the lung causes 
a flattening of the chest wall, raising of the diaphragm 
and displacement of the mediastinum and heart toward 
the affected side. Change in the position of* the ribs 
causes depression of the shoulder and curvature of the 
spine. The respiratory movements over the affected 
area are restricted in proportion to the extent of the 
disease. The opposite side will be in a state of com- 
pensatory emphysema and functional activity. 

Diffuse Type. — In the emphysematous form the 
shape and size of the chest and the respiratory move- 
ments will correspond to those described under Large 
Lung Emphysema (see Emphysema). In the con- 
tracted form the shape of the chest is more or less 
analogous to the small lung or senile form of emphy- 
sema. There is contraction of the lower portion of the 
thorax; the intercostal spaces are narrowed; the ribs 
may overlap. Expansion of the lung is deficient ; the 
diaphragm is carried upward, and the supraclavicular 
and suprasternal spaces are deepened. It is rare for 
this condition to be uniform or equally marked on 
both sides. In tuberculosis one entire lung may be 
involved, while in the other it may be limited to the 
apex. When secondary to mechanical bronchitis, the 
changes are more uniform. 

Palpatio^. — Vocal fremitus is variable, and gives 



DISEASES OF RESPIRATORY TRACT. 177 

important information as to the nature of the change in 
the lung and the extent of the involvement. In the 
massive or lobar type there will be increase in vocal 
fremitus. In the broncho-pneumonic type the change 
in vocal fremitus will correspond to the extent of the 
disease and its nearness to the surface of the lung. 
The vocal fremitus may be feeble or absent when there 
is obstruction of the bronchi leading to the affected area, 
and when there is marked thickening of the pleura. In 
the diffuse type vocal fremitus is markedly diminished 
in the emphysematous form. In the contracted form it 
may be increased, but usually, on account of its associa- 
tion with pleural thickening, it is feeble or absent. The 
localization of the disease also causes variations in the 
intensity of the vocal fremitus. Fibrosis of the apex is 
usually attended with increased vocal fremitus, while 
when the base is involved the vocal fremitus is dimin- 
ished or absent. 

Percussion. — Increase of the solid structure of the 
lung causes dullness of the percussion note. Loss of 
tension of the lung and diminution in the size of the 
alveoli causes the dullness to have a peculiar wooden 
and tympanitic quality. Thickening of the pleura 
causes a more marked dullness, with increased sense of 
resistance. In the emphysematous form the increase 
in the size of the alveoli causes the percussion note to 
be hyper-resonant. 

Auscultation. — In the lobar type the breath sounds 
are bronchial in character and more or less weakened, 
but differ from those present in true lobar pneumonia 
in being less intense and having a somewhat soft, blow- 
ing quality. Bronchophony is also present, but is weak 
and distant. 

In the broncho-pneumonic type, if the area involved 
is close to the surface of the lung, bronchial or broncho- 
vesicular breathing will be present. When situated 
deeper in the lung and covered by distended alveoli, 
bronchial breathing may be absent, and the respiratory 
12 



178 THE RESPIEA Ton V SYSTEM. 

murmur will be feeble. When rales are present over 
the affected areas, they will have a sharp, metallic 
quality. In the disseminated type one of the character- 
istic features is the feehleness or absence of the vesicular 
element of the inspiratory sound, associated with feeble, 
prolonged and slightly bronchial expiratory sound. 
Pleural changes cause both the vesicular and bronchial 
elements of the breath sounds to be weakened or 
obliterated. 

Differential Diagnosis. — The differentiation of the 
fibrosis that occurs in tuberculosis from that of non- 
tubercular diseases of the chest is frequently impossible. 
Fibrosis always occurs in certain forms of tubercular 
infection of the lung, and has no distinctive features. 
The condition known as coal miners' phthisis, fibroid 
phthisis, etc., is frequently due to the combination of 
dust irritation and tubercular infection. Frequently 
the fibroid changes in the lung are so marked as to 
become the most important factor, while the tubercular 
changes are subsidiary. 

EMPHYSEMA. 

Pulmonary vesicular emphysema is an overdistension 
of the air-vesicles, and may be acute or chronic. The 
varieties of emphysema are: (1) Compensatory or 
vicarious. This may be limited to a few lobules, to a 
lobe or involve one lung only. This type of emphysema 
occurs when distension of a portion of the pulmonary 
tract is compensatory for deficient expansion in other 
portions of the lung. 

(2) General vesicular emphysema. In this variety, 
associated with dilatation of the air-vesicles, are struct- 
ural changes in the walls of the alveoli which diminish 
their resiliency and lead to atrophy. Two types of 
general emphysema are recognized : (a) Chronic, large 
lung or hypertrophic emphysema, and (b) small lung, 
atrophic or senile emphysema. 



DISEASES OF RESPIRATORY TRACT. L79 

(3) Interlobular or interstitial emphysema, with 
infiltration of air into the pulmonary stroma. 

In general, chronic, large-lung emphysema the most 
marked change, in addition to increased dilatation of 
the alveoli, is a loss of elasticity of the alveolar walls, 
which influences the respiratory function. As has 
been mentioned before, while the pulmonary tissue is 
passive during inspiration, merely dilating with 
enlargement of the thorax, during expiration it is active, 
and plays a most important part in contracting the 
chest. Perfect respiration requires that the chest be 
contracted as well as expanded. The power of the 
lung to contract is due to (a) elasticity of the alveoli ; 
(b) contraction of the muscular tissue of the bronchial 
tract. 

In proportion as the normal elasticity of the pul- 
monary tissue is impaired in emphysema, the following 
conditions are induced: (a) Faulty expiratory con- 
traction leads to gradual overdistension of the lungs, 
increase in the amount of residual air and diminution 
in the amount of tidal air. The chest wall, unacted 
upon by the elasticity of the lung, assumes at first the 
position of full inspiratory expansion. As the ventila- 
tion of the lung is imperfect, dyspnoea is easily induced 
on exertion, and the accessory inspiratory muscles are 
called into play to increase still further the capacity of 
the chest. The upper portion of the bony thorax is 
carried upward ; the sternum is carried forward ; ribs 
rotated outwards ; the intercostal spaces widen ; antero- 
posterior diameter of the chest increases. "Enlarge- 
ment of the chest to the limit of thoracic resiliency 
occurs." (Powell.) Enlargement of the lung dis- 
places the heart toAvards the median line, and the dia- 
phragm is depressed, together with the abdominal 
organs. 

(b) Circulatory changes. The circulatory system is 
affected in two ways: (1) Normally the elasticity of 
the lung causes a negative pressure within the thorax, 



180 THE RESP1& I TOR V 8 Y8TEM. 

which, during inspiration, equals 7 to 9 mm. of mercury. 
"The elastic fibres of the lung are upon the stretch and 
arc pulling upon the ribs, intercostal spaces, upon the 
diaphragm and upon the heart and great vessels. The 
elastic pull of the lung . . . assists the diastolic 
expansion of the ventricles . . . and acts upon 
the vena cava within the chest and generates within 
them, as well as within the right auricle, a force of suc- 
tion. This suction from within the chest extends to the 
great veins just without it in the neck." 1 

As the elasticity of the pulmonary tissue becomes im- 
paired, the suction force of the lung decreases ; there is 
a corresponding imperfect dilatation of the right auricle 
and emptying of the great veins. This interferes with 
the return circulation, which earlv shows itself in dis- 
tension of the jugular veins and a tendency to general 
venous stasis. 2 (2) The dilatation of the alveolar 
walls, with the subsequent atrophy, causes obstruction 
to the pulmonary circulation through narrowing the 
capillaries, by stretching and by obliteration. The 
effect of this circulatory obstruction is to raise the press- 
ure in the pulmonary artery, which is early indicated by 
accentuation of the pulmonic second sound. To over- 
come the increased tension in the pulmonary artery, the 
right heart hypertrophies ; sooner or later the hyper- 
trophy fails to keep pace with the progressive obstruc- 
tion of the pulmonary circulation and the increased 
work. The right ventricle is unable to empty itself; 
dilatation of the cavity occurs, with incompetency of the 
tricuspid valve, and regurgitation in the right auricle. 
When tricuspid regurgitation occurs, the imperfect 
venous return, due to diminished negative pressure, is 
acutely increased. Pulsations occur in the jugular 
vein; there is passive congestion of all the abdominal 
viscera, with enlargement of the liver and spleen, the 
occurrence of ascites and general anasarca. 



1 American Text-Book of Physiology, Vol. I, p. 95. 

2 In compensatory .emphysema the decrease in negative pressure is not 
present. In the senile type it is not a marked feature of the disease. 



DISEASES OF RESPIRATORY TRACT. 181 

Physical Signs. — The physical signs of emphysema 
vary with the degree of pulmonary distension and loss 
of elasticity. They arc modified by intercurrent attacks 
of acute bronchitis, spasm of tin 4 bronchi (asthma) and 
the secondary changes in the circulatory system. 

Inspection. Large-Lung Emphysema. — The patient 
presents a more or less characteristic appearance. The 
chest is enlarged in all directions, especially in the 
antero-posterior diameter. The dorsal curve of the 
spine is exaggerated. The sternum is carried forward; 
the ribs are rotated outward and are more horizontal; 
the upper intercostal spaces are widened, and the lower 
portion of the chest is seemingly contracted in com- 
parison with the upper portion, but there is an increase 
in the transverse diameter. These changes in the bony 
thorax give the barrel-shaped chest of emphysema. 
Mensuration shows enlargement of the thorax is in 
all directions, especially marked in antero-posterior 
diameter. 

The movements of the thorax are altered ; inspiration 
is short, jerky, with very slight expansion from first to 
fourth ribs. The muscles of the neck are hypertrophied 
and prominent, the upper portion of the chest being 
pulled upwards by the accessory muscles of inspiration. 
With inspiration the suprasternal, supraclavicular and 
upper intercostal spaces are deepened. The lower por- 
tion of the chest is depressed during inspiration by the 
action of the diaphragm, and breathing is chiefly 
abdominal. 

Expiration is tardy, slow and prolonged, with forcible 
contraction of the abdominal muscles. During expira- 
tion the intercostal spaces may be even with, or project 
beyond, the level of the ribs. Cardiac impulse is not 
seen in the normal site, but is displaced downward and 
inward. Epigastric pulsation is marked. The jugular 
veins are prominent and, in tricuspid regurgitation, 
pulsating. 

Small-Lung Emphysema. — The patient has the 
wasted, shrunken appearance of old age. The thorax is 



1 - s - THE EESPIB. I TOR Y SYSTEM. 

contracted, the shoulders arc rounded, but the clavicles, 
ribs and sternum are depressed; the intercostal spaces 
are narrowed below the fourth rib. The lower ribs are 
very oblique, and the edges may be in contact. The 
movements of respiration are shallow; the thorax is 
more rigid than in the large-lung type. During inspira- 
tion there is deepening of the supraclavicular fossa and 
intercostal spaces. The diaphragm is not depressed, 
but its descent is limited. Cardiac impulse is not dis- 
placed downward and toward the median line, as in the 
large-lung type, but may be slightly elevated and carried 
further to the left. Epigastric pulsation and distension 
of the jugular veins are absent. 

Compensatory Emphysema* — When compensatory 
emphysema involves the entire lung, the enlargement of 
the side is attended with movements of increased func- 
tion, i. e., increased expansion during inspiration, while 
in expiration the contraction of the thorax is energetic 
and prolonged. The cardiac position varies with the 
cause of the emphysema and the side involved. 

Emphysema limited to a lobe or part of a lobe will 
affect the size, shape and movement of the thorax, 
according to the cause. When emphysematous dilata- 
tion occurs in portions of the lung surrounding areas of 
consolidation or induration, it may prevent the 
deformity that is usually associated with the primary 
condition. 

Palpation. Large-Lung Emphysema. — Vocal frem- 
itus varies in proportion to the rarefaction of the lung 
and the diminution of pulmonary tension. It may be 
normal in mild cases, diminished or absent in well- 
marked. Cardiac impulse felt in the epigastric region 
is diffuse; the force depends entirely upon the degree 
of hypertrophy of the right ventricle. The liver may 
be felt below the free border of the ribs ; the edges are 
firm, smooth and rounded in proportion to the conges- 
tion from disturbed venous return in the vena cava. 
The spleen may be enlarged and palpable, secondary to 



DISEASES OF RESPIRATORY TRACT, L83 

hepatic congestion. When emphysema is associated 
with bronchitis or spasm of the bronchi, rhonch] may be 
felt. 

Small-Lung Emphysema. — Vocal fremitus is but 
slightly changed, and may show slight increase in 
intensity, especially over the areas of large bronchi. 

Compensatory Emphysema. — Increased tension of 
the lung causes the normal vocal fremitus to be sliffhtly 
increased. 

Percussion. — Large-Lung Emphysema. — Rarefac- 
tion of pulmonary tissue and increased amount of air 
contained in the thorax causes the percussion note to be 
hyper-resonant; the low tension of the pulmonary tissue 
lowers the pitch. The condition of the chest wall (page 
S4) permits the bony quality to be added to that of the 
pulmonary tissue, so that the quality is changed. 
According as these different elements enter into the per- 
cussion sound, it has been described as vesico-tympanitic, 
band-box, boardy, woodeny, etc. The character of the 
sound does not show variation during inspiration and 
expiration. The borders of the lung are extended, and 
resonance may be obtained as low as the twelfth rib 
behind. The normal areas of hepatic and cardiac dull- 
ness are diminished or absent. 

Small-Lung Emphysema. — The percussion note is 
hyper-resonant, but the pitch is not lowered ; the quality 
is clearer and more tympanitic than in the large lung 
type. The areas of cardiac dullness are not diminished, 
but may be increased by retraction of the pulmonary 
borders. Hepatic dullness is slightly higher than nor- 
mal. The rigid chest wall gives an increased sense of 
resistance. 

Compensatory Emphysema. — In acute cases all the 
elements of normal percussion sounds are exaggerated. 
The note is hyper-resonant, clear and slightly higher in 
pitch. 

In long-standing cases, secondary changes in the lung 
may cause loss of tension and the percussion sound of 



5 



184 THE RESPIR. I TOE Y SYSTEM. 

the large-lung emphysema. In chronic localized emphy- 
sema the percussion note varies according to the condi- 
tions with which it is associated. 

Auscultation. — Large-Lung Emphysema. — During 
inspiration the vesicular murmur is short, feeble, or 
may be inaudible, being replaced "by a low-pitched, 
rumbling sound of muscular contraction." (Fowler.) 
During expiration the breath sound is prolonged, and 
continues with nearly equal intensity to the end of the 
act. In direct proportion to the severity of the disease, 
the ratio of the length of inspiration to expiration is 
altered. Expiration becomes longer than inspiration, 
sometimes reversing the normal ratio, being four times 
as long as inspiration. The pitch is low, and the quality 
slightly blowing. When emphysema is associated with 
bronchitis and spasm of the bronchi, various-sized dry 
and moist rales are heard (spasmodic emphysema). 

When emphysematous blebs have formed beneath the 
pleura, fine crackles are heard with inspiration and 
expiration, or both (fine crackling crepitations, emphy- 
sematous gurglings). With the failing right heart, 
fine, moist, crepitating rales, due to pulmonary oedema, 
are heard over the base of the lungs. 

Cardiac sounds are not heard over the normal area, 
and vary according as hypertrophy or dilatation is most 
marked. Over the normal apex of the heart the first 
sound is low pitched and prolonged in hypertrophy, 
short and sharp when dilatation and cardiac weakness 
occur. Over the base the cardiac sounds are heard at a 
lower level than normal, and there is accentuation of 
the second sounds to the left of the sternum, due to 
increased tension of the pulmonary artery. A systolic 
murmur is frequently present over the displaced apex. 
At first this may be present only after exertion, or dur- 
ing transient attacks of intercurrent bronchitis. Later 
it may be permanent, with all the associated signs of 
tricuspid regurgitation. Cardiorespiratory murmurs 
are at times present over the normal area of cardiac 
dullness. 



DISEASES OF RESPIEATOEY TRACT. 185 

Small-Lung Emphysema. — The deviations from nor- 
mal are not as marked as in the large lung. The 
inspiratory sound is nearly normal in length, but feeble. 
The expiratory sound is prolonged, but rarely exceeds 
the length of inspiration; is harsher, and its pitch is not 
as low. 

Compensatory Emphysema. — Breath sounds are 
exaggerated. They retain their normal characteristics, 
but are pure in type. 

Differential Diagnosis. — The distinctive signs of large- 
lung emphysema are bilateral enlargement of the chest, 
with increase in the antero-posterior diameter and 
rounded contour (barrel-shaped chest) ; widening of the 
intercostal spaces ; restricted inspiratory movement, 
with prolonged and labored expiration ; displacement of 
the apex beat and epigastric pulsation. 

Feeble vocal fremitus, associated with hyper-resonant 
and low-pitched percussion note. 

The inspiratory portion of the breath sounds is short, 
feeble or absent, while the expiratory portion is pro- 
longed, low pitched and relatively more intense. 

Pneumo-thorax. — Enlargement of the thorax is not 
symmetrical, but more marked over the affected side. 
The intercostal spaces of the affected side are obliter- 
ated. Movements of the two sides are unequal. There 
is absence of motion on the affected side, with active 
movement of the opposite. The heart is displaced 
toward the unaffected side. The percussion note is 
hyper-resonant, but of tympanitic quality, the normal 
vesicular quality being absent. Coin test shows a 
peculiar metallic quality of sound. Vocal fremitus is 
absent. Vesicular murmur is absent. Amphoric 
breathing is present on inspiration and expiration when 
the opening to bronchus is patent. Lung fistula sound 
at times detected. 

Hydro-pneumo-thorax. — Below level of fluid there is 
flatness on percussion. On shaking the patient succus- 
sion sounds may be detected, with metallic tinkles. 



ISO THE RESPIRATORY SYSTEM. 

Cardiac Dyspnoea. — In acute febrile diseases and in 
anaemia, physical signs similar to those obtained in a 
mild degree of emphysema are frequently present, espe- 
cially the hyper-resonant, low-pitched percussion note. 
This is differentiated from true emphysema in that the 
respiratory sounds retain their normal relation to each 
other. 



ASTHMA. 

Asthma is a disease characterized by attacks of 
intense dyspnoea of a paroxysmal type, occurring more 
or less sudUenly. 

Attacks of asthmaic dyspnoea may be due to acute 
narrowing, of the lumen of the bronchial tubes by (a) 
spasm of the muscles of the bronchi (idiopathic or true 
asthma), (b) vaso-motor dilatation of the blood-vessels 
or inflammatory swelling of the mucous membrane 
(secondary asthma). 

Between the attacks in the primary type the respira- 
tory tract may be normal. In the second type it shows 
the change of the primary condition. 

Condition of Lungs During Asthmatic Attack. 
— In proportion to the intensity of the attack, there is 
increase in the amount of residual air and a correspond- 
ing decrease in the quantity of tidal air, with resultant 
overdistension of the alveoli. The chief factor in caus- 
ing interference with the normal movement of the air 
during inspiration and expiration is the spasmodic con- 
traction of the muscular tissue present in the bronchial 
tubes. Muscle fibres have been demonstrated in the 
bronchial tract as far as the infundibula. The muscle 
fibres of the bronchi are passive during inspiration, but 
during expiration their contraction is an important fac- 
tor in forcing the air out of the lung and in the produc- 
tion of normal expiratory breath sounds. 

During an asthmatic attack the normal rhythmical 
action of the bronchial muscles is disturbed. With 



DISEASES OF RESPIRATORY TRACT, 187 

expiration the contractions are excessive, narrowing the 
lumen of all the tubes, and even closing entirely the 
smaller ones, especially the non-cartilaginous. With the 
following inspiration active contraction of the muscle 
ceases, but more or less spasm remains, so that 
there is persistent interference with the -movement of air 
in the king; but it is not so great as during expiration. 
In mild attacks the inspiratory obstruction may not be 
present. With each respiratory act more air is taken 
in than is expelled, until the thorax is distended to the 
utmost; there is imperfect ventilation of the lung and 
deficient oxygenation of the blood, with attending 
symptoms of dyspnoea. The effect of an asthmatic 
attack is overdistension of the lung, causing depression 
of the diaphragm, enlargement of the thoracic cavity in 
all directions ; the heart is displaced downward and 
toward the median line. 

Contraction of the bronchi and overdistension of the 
alveoli cause diminution of the normal negative inter- 
thoracic pressure during inspiration, and may give rise 
to positive pressure during both inspiration and expira- 
tion, which in turn causes interference with pulmonary 
circulation, overdistension of the right ventricle, and 
interference with venous return circulation. 

With the subsidence of an attack, the pulmonary con- 
dition may return to normal. Repeated and long- 
continued attacks of asthma gradually produces 
permanent dilatation of the air-vesicles and secondary 
emphysema. 

Physical Signs. Inspection. — (a) During attach: 
The face may be pale or slightly cyanotic ; the patient 
generally sits up in the position to give greatest leverage 
to auxiliary muscles of respiration; the shoulders are 
elevated ; the chest assumes the barrel shape of emphy- 
sema. With inspiration, the muscles of the neck, espe- 
cially the sterno-cleido-mastoid, are prominent, and 
cause the movements of the chest to be short and jerky, 
lifting the thorax en masse, but with very little expan- 



188 THE RESPIRA TOR Y SYSTEM. 

sion. Interference with the free entrance of air into 
the alveoli causes depression of the soft parts, so that 
the suprasternal, supraclavicular and intercostal spaces 
are deepened. The diaphragm is forced to the lowest 
point possible, the lower portion of the thorax and 
sternum are depressed, and the epigastric region becomes 
more prominent. Expiration follows inspiration with- 
out a pause, and is prolonged, labored, but feeble. 
Movement of thorax is very slight, and due to the action 
of the auxiliary muscles of expiration, which, forcing 
the bony thorax against the inflated lung, cause bulging 
of the intercostal spaces and supraclavicular fossae. 
Respirations are not increased in frequency, and may be 
less than normal. Jugulars are distended, and the apex 
beat is displaced downward and to the right, with 
marked epigastric pulsation. 

(b) Between the attacks: the condition of the lungs 
may be normal. When asthma has produced permanent 
dilatation of the air-vesicle, the shape and movement of 
the thorax are those of emphysema. 

Palpation. — (a) During attack: vocal fremitus 
never increased ; may be diminished or absent. Over a 
given area it varies from time to time, according to the 
degree of contraction of bronchi leading to the part. 
Rhonchi may be felt. The cardiac impulse is displaced 
downward to the right, and is diffused; pulse is small 
and intermittent, especially during inspiration (pulsus 
paradoxus), (b) Between the attacks: vocal fremitus 
is normal or diminished, as in emphysema. 

Percussion. — (a) During attack: percussion sound 
hyper-resonant. During early stage of the disease, 
with increased tension in the lung, the sound is slightly 
higher pitched, but clear. After repeated attacks, the 
diminished elasticity of the lung causes the pitch to be 
altered (lower) and the quality to be tympanitic or 
boardy (see Emphysema). Enlargement of the lung 
causes cardiac and hepatic areas of dullness to dis- 
appear. The borders of lungs are extended, and show 



DISEASES OF BESPIRATORY TRACT. ISO 

no variation between inspiration and expiration, (b) 
Between the attacks: resonance 4 may be normal or more 
or less emphysematous. 

Arson .tat ion. — (a) During attacks: inspiratory 
vesicular murmur may be heard from time to time. 
When present, it is of normal quality, but weak, short 
and jerky. Usually it is absent or obscured by sibilant 
or sonorous rales. 

During expiration respiratory murmur is usually 
absent, being replaced by prolonged, dry rales of sonor- 
ous, sibilant, cooing or whistling type. The rales are 
constantly changing in intensity and character over a 
given area, at times disappearing, either with return of 
normal vesicular murmur or absence of all sound. 
With subsidence of the attack, large and small-sized 
moist rales are present, due to secretion in the bronchi. 

When asthmatic attacks occur during the course of 
acute or chronic bronchitis, the dry and moist rales are 
both present. Vocal resonance is normal or somewhat 
diminished; cardiac sounds during attack are masked 
by dry rales in the lung. 

(b) Between the attacks: respiratory sound may 
return to the normal, or a few wheezing rales may he 
present for some time after dyspnoea has disappeared. 
After severe attacks, fine, bubbling, moist rales, with 
feeble respiratory murmur, may be heard for some 
hours or days over the base of the lung and along the 
borders. In chronic cases, emphysematous breathing is 
present between the attacks. 

Differential Diagnosis. Cardiac Dyspnoea. — Subjects of 
valvular and myocardial disease of the heart may suffer 
from intercurrent attacks of spasmodic dyspnoea. It 
has the following physical signs which differentiate it 
from asthma : 

Inspection. — The breathing is sighing or panting in 
character; the rate is increased; the movements of 
inspiration and expiration are of nearly equal length. 
Expiration lacks the characteristic prolongation of 



100 THE RESPIRATORY SYSTEM. 

asthma. The chest lacks the typical distension of 
asthma. In asthma breathing is spasmodic, with in- 
spiration short ; expiration, prolonged and labored. The 
rate of respiration not increased. 

Percussion. — In cardiac dyspnea the note over the 
upper portion of the chest is normal. Over lower por- 
tion of the chest, especially at the base, posteriorly, dull- 
ness is more or less marked, in proportion to the amount 
of pulmonary oedema and passive congestion. 

In asthma the note is hyper-resonant over all portions 
of the chest, especially at the base. 

Auscultation. — In cardiac dyspnoea during inspira- 
tion, vesicular murmur is present over upper portion of 
lung; over base it may be feeble or absent, according to 
the amount of pulmonary congestion and oedema. 

The relative length of inspiration and expiration is 
but slightly altered. Rales, both dry and moist, may be 
present, but dry rales are not as varied and are more 
constant than in asthma ; while moist rales are relatively 
more abundant, especially over the base. In chronic 
passive congestion (cardiac pneumonia) the breath 
sounds may have a bronchial quality. When dyspnoea 
is due to valvular disease, the physical signs of the lesion 
are usually present. At times the distinguishing signs 
in the lung may be intense enough to mask the cardiac 
murmurs. 

In asthma dry rales are the most prominent. When 
detected, breath sound is normal, never bronchial. 

Laryngeal and Tracheal Stenosis. Inspection. — 
Dyspnoea is inspiratory with increased movement of 
the larynx. Size of the chest is diminished ; the dia- 
phragm is elevated; there is marked retraction of the 
suprasternal, supraclavicular and intercostal spaces. 
Inspiratory portion of respiration is prolonged and 
labored. Expiratory movement is shorter than normal. 
In asthma the dyspnoea is chiefly expiratory; the chest 
is enlarged; the diaphragm is depressed. 



DISEASES OF RESPIRATORY TRACT, 101 

Percussion. — In stenosis the percussion note lias 
diminished resonance. In asthma it is hyper-resonant. 

Auscultation. — In stenosis, vesicular murmur over 
the lung is diminished or feeble; the stridor, due to the 
narrowing of the larynx, frequently cause bronchial 
type of breathing to be heard over both lungs. The 
changes in the respiratory sounds are constant. In 
asthma, dry rales of varying size are heard over a given 
area, constantly changing in character. 

Aneurism of the Aorta. — Compression by the aneuris- 
mal sac of the trachea and left bronchus may simulate 
very closely an asthmatic attack. The physical signs 
are not bilateral. The intensity of the signs will 
depend on the degree of narrowing. When the bronchus 
is only slightly narrowed, the respiratory sound heard 
over the lung beyond the point of constriction may have 
a slightly tubular or a marked sonorous quality. Entire 
occlusion of the bronchus causes absence of breath sound 
over portion of lung supplied by the tube. Dullness 
over the sternum and tracheal tugging, brassy cough, 
and heaving impulse are generally sufficient for diag- 
nosis. 

Hysterical Breathing. — Paroxysmal and labored breath- 
ing, similar to that of asthma, occurs during hysterical 
attacks. Expansion of the chest, due to voluntary 
action of the muscles of inspiration, and voluntary inter- 
ference with expiration, may be identical with that of 
asthma. The rate of the breathing is generally 
increased. 

On auscultation the dry rales, with prolonged expira- 
tion are not present. 

PULMONARY TUBERCULOSIS. 

Synonyms. — Phthisis, consumption. 

Pulmonary tuberculosis is a disease of the lungs, due 
to the presence of the tubercle bacilli, with the produc- 
tion of tubercular nodules. 

The distribution of the tubercles may be localized or 



1 02 THE RESPIRA TOR V SYSTEM. 

diffuse. The primary effect is the same in both eases, 
varying merely in degree. When localized, its point of 
selection is usually the apex, although certain factors 
may determine its primary location in other portions of 
the lung. When more widely distributed, it may 
involve an entire lobe or lung, or may be disseminated 
throughout the entire bronchial tract. 

Effect Upon the Lung. — Immediate lodgment of the 
tubercle bacilli usually occurs in the terminal bron- 
chioles. With the production of the tubercular nodule, 
the bronchiole becomes occluded, and the alveolus 
supplied by the bronchiole becomes the seat of an inflam- 
matory 23rocess, with the production of broncho-pneu- 
monia. The peribronchial tissue is also involved. 
Extension to neighboring lobules occurs through the 
lymph spaces and vessels into the interstitial tissue, and 
also through the bronchi. On account of the relation 
of the lymphatics of the interlobular tissue to the pleura, 
there is early involvement of the subpleural tissue, with 
secondary involvement of the pleural sac, which may, 
however, not be of a tubercular nature. 

Secondary Changes. — Dependent upon tubercular in- 
fection, three varieties of pathological changes occur : 
(1) Congestion, inflammation and oedema of the tissues 
adjacent to the tubercular nodule, producing more or 
less complete consolidation of the alveoli, with inflam- 
matory products (catarrhal, broncho-pneumonia). (2) 
Necrosis (caseation, liquefaction, softening) of the 
infected area. (3) Growth of connective tissue (fibro- 
sis). These three processes occur together, and are 
present in varying degrees. As one or another pre- 
dominates in an individual case, the rapidity of its 
course and the type of the disease is determined. 

Two forms of pulmonary tuberculosis occur: A. 
Acute. B. Chronic. These can be still further sub- 
divided into types, according to (a) distribution of the 
infection; (b) the character of the changes in the 
infected area. 



DISEASES OF RESPIRATORY TRACT. L93 

A. Acute Pulmonary Tuberculosis. 

Three types may be recognized clinically: (1) Acute 
miliary tuberculosis, pulmonary type. In this form of 
the disease the tubercle bacilli are widely distributed 
throughout the lung. The eruption of tubercles is very 
rapid, and the inflammatory changes in the alveoli and 
adjacent bronchi are very marked. These early changes 
in the lung are almost identical with those that occur in 
acute capillary bronchitis with involvement of the 
alveoli. The necrosis and liquefaction occur almost at 
once, while there is almost complete absence of con- 
nective tissue increase. 

(2) Broncho-pneumonic type. In this form the 
eruption of tubercular nodules is at first localized in the 
apex of one or both of the upper lobes, or tubercular 
foci may be scattered throughout the lung. The areas 
involved in the tubercular process are the seat of an 
intense catarrhal inflammation, and caseation, with 
liquefaction and cavity formation, occurs very rapidly ; 
so that the lung passes in a short time through the stages 
of infection, tuberculization, infiltration (broncho- 
pneumonia), and softening, with the production of a 
number of small cavities. The tubercular masses may 
coalesce, forming a confluent broncho-pneumonia. 

(3) Lobar type. Occasionally the amount of tissue 
involved by a confluent area of tubercular broncho-pneu- 
monia may be so great as to involve nearly an entire 
lobe, giving consolidation as extensive as is found in 
acute croupous pneumonia. 

On account of the rapidity of the changes and the 
nature of the physical signs, various names have been 
given to this form of acute pulmonary tuberculosis, as 
acute phthisis, acute pneumonic phthisis, tubercular 
pneumonic phthisis, caseous tubercular pneumonia, 
broncho-pneumonic phthisis, acute catarrhal phthisis, 
epithelial phthisis, florid phthisis, galloping consump- 
tion. 

13 



194 THE RESPIRATORY SYSTEM. 

Physical Signs. — In the acute miliary type the earliest 
changes may be those of general bronchitis, gradually 
increasing in intensity with the occurrence of broncho- 
pneumonia. In the early stage of acute miliary tuber- 
culosis, the signs are identical Avitli those described 
under Capillary Bronchitis with involvement of the 
bronchioles and alveoli (page 144), the dyspnoea, how- 
ever, is more marked and persistent. Where the dis- 
ease is localized, the following signs may be present: 

Inspection. — In the broncho-pneumonic type, in the 
early stage, there is no change in the shape of the chest. 
With occlusion of a large number of bronchi and pul- 
monary collapse, there is depression of the thorax over 
the affected area, with loss of motion. With the occur- 
rence of liquefaction (softening) and the formation of 
cavities, the depression may become less marked, and 
motion may return. 

In the lobar type there may be loss of motion over a 
wider area, while more complete consolidation of the 
lung causes absence of thoracic depression. 

Palpation. — In the broncho-pneumonic type vocal 
fremitus may be normal when the disease is deep seated, 
and feeble when there is marked pulmonary collapse. 
When the consolidation is close to the surface, vocal 
fremitus is slightly increased. 

In the lobar type vocal fremitus may be as intense 
as in true croupous pneumonia. 

Percussion. — In the early stage the percussion note 
may be normal. Over the portion of lung affected by 
obstruction of the bronchi, the percussion note is dull, 
with slight tympanitic quality. Later there is gradual 
increase of dullness, according; to the decree of consoli- 
dation. When pleural changes are present, dullness 
may almost reach the degree of flatness. With cavity 
formation, the dullness is replaced by cavernous or 
amphoric percussion resonance. 

Auscultation. — The earliest signs over the affected 
area are those of diffuse bronchitis, with sibilant and 



DISEASES OF RESPIRATORY TRACT. 195 

sonorous rales and moist rales of a liquid, bubbling 
character. The breath sounds may be weak in occlu- 
sion of the bronchioles and pulmonary collapse. As the 

collapsed lung becomes consolidated by inflammatory 
products, the breath sounds become bronchial in char- 
acter, but rarely tubular. The liquid, bubbling rales 
of bronchitis are replaced by sharp, crepitating rales 
and by pleuritic friction sounds. As softening occurs, 
the small rales are replaced by coarser ones, and the 
bronchial breathing loses its sharpness and lias a hollow, 
blowing qualitw; it rarely becomes markedly cavernous 
or amphoric. The slower the course of the disease, the 
greater the tendency for the areas of consolidation to 
coalesce, with a corresponding increase in the intensity 
of the bronchial quality of the breath sounds. As the 
different tubercular areas do not undergo the changes of 
consolidation, softening and cavity formation with the 
same degree of rapidity, the physical signs of all stages 
of the disease will be found in different portions of the 
lung. In the localized broncho-pneumonic and lobar 
types, the disease may at any stage lose its acute char- 
acter and pass into the subacute or chronic form. 

Differential Diagnosis. Simple Broncho-Pneiimon la. 
— As stated above, the early physical signs are identical 
in the tubercular and non-tubercular forms. As the dis- 
ease advances to the stage of softening, slight differences 
may be noted. In the simple, non-tubercular pneumonia 
resolution occurs at a uniform rate over the affected 
areas, with a gradual return to the normal condition. 
In the tubercular type, with softening and destruction 
of the lung tissue, rales become larger than those com- 
mon in bronchi of normal size. The bronchial character 
of the breath sounds is gradually replaced by soft, blow- 
ing, puffing breath sounds, especially marked on expira- 
tion. In the lobar pneumonic form the physical signs 
may be for a time identical with those of croupous 
pneumonia, but later certain changes develop in the 
consolidated lung which differ. The vocal fremitus 



196 THE RESPIRATORY SYSTEM. 

over the consolidated area, while it may be as intense as 
that found in the second stage of croupous pneumonia, 
is not uniform over all portions of the lobe involved. 
During the period of softening, vocal fremitus does not 
diminish to the same degree in the tuberculous cases. 
On auscultation, fine crepitating rales of the first stage 
of croupous pneumonia may be present, but they are not 
as fine nor as sharp, and do not occur in well-defined 
showers. They do not disappear with the occurrence of 
bronchial breathing, as in croupous pneumonia, but per- 
sist until replaced by the coarser rales of softening. 
With the beginning of softening, the rales of tubercular 
pneumonia may be identical with those of resolving 
croupous pneumonia (rales redux), but they tend to 
become larger, and are later replaced by mucous clicks 
and gurgles. In croupous pneumonia the rales are 
uniform in size, and become fewer as resolution occurs. 

The bronchial breathing of tubercular pneumonia 
does not disappear with the signs of softening, but, 
while it may for a time be more or less masked by rales, 
it reappears over scattered areas and has a hollow, 
cavernous or amphoric quality. In croupous pneu- 
monia the bronchial quality of the breath sounds 
gradually fades out as resolution proceeds. 

While the above physical signs may aid in differen- 
tiating tubercular from non-tubercular lobar pneumonia, 
the most important data are obtained by the tempera- 
ture, duration and course of the disease, and micro- 
scopical examination of the sputum. In tubercular 
pneumonia the physical signs of softening are not asso- 
ciated with the phenomenon of crisis and lowered range 
of temperature. The expectoration of tubercular pneu- 
monia is apt to be grayish-green (Traube), differing 
markedly from the tenacious, blood-stained (brick dust) 
sputum of croupous pneumonia. 



DISEASES OF RESPIRATORY TRACT. !'*< 



(B) Chronic Pulmonary Tuberculosis. 

In the subacute and chronic forms of pulmonary 
tuberculosis, following loca] infection by the tubercle 
bacilli, pathological changes occur which are of the 
same general nature as those of the acute form, but 
differ in the degree of severity and in their course. 

In these forms the disease is more distinctly localized. 
With the development of the tubercular nodules, there 
may be congestion, inflammation and oedema of the 
affected lobules, giving the pathological changes and 
physical signs of localized acute bronchitis or acute 
pneumonia, as was described in the acute forms. These 
acute conditions subside, and the disease runs a milder, 
more subacute or chronic course. In the large majority 
of cases the incipient stage is more insidious, and with 
the local infection there is little or none of the acute 
inflammatory change, but a progressive increase of the 
connective tissue (fibrosis), which extends outward 
from the site of infection along the interlobular septa 
to the surface of the lung, and early involves the 
pleural and subpleural surfaces, causing thickening and 
adhesion. The bronchi in the affected area are nar- 
rowed or occluded, with subsequent pulmonary collapse. 
The fibrosis and changes in the bronchi and alveoli 
cause imperfect expansion of that portion of the lung 
and retraction of the tissues of the thorax over it, unless 
the functionless portion is compensated for by the 
adjacent overlying lobules. During the early or 
incipient stage, all degrees and extent of these patho- 
logical changes may be present at different times in the 
same case. Their relative preponderance determines 
the type of the disease and influence its course. The 
physical signs present will be those of localized bron- 
chitis, catarrhal pneumonia, fibrosis and pleurisy. The 
more marked the fibrosis, the more latent and chronic 
the course. 



1 ( - )S THE BESPIB. 1 TOR V SYSTEM. 

The disease may be arrested in this stage by encapsu- 
lation of the tubercular area by a dense fibrous envelope. 

Usually (second stage) there is extension of the tuber- 
culous infiltration to adjacent portions of the same lobe, 
as described below. This extension is along fairly 
definite lines, and is usually associated with more or less 
consolidation, due to connective tissue increase. With 
the extension of the disease there is corresponding 
involvement of the pleura, which may be acute, sub- 
acute, adhesive or pleurisy with effusion. The con- 
solidation is never as complete as in croupous pneu- 
monia. 

Sooner or later, in the majority of cases, necrosis 
(third stage) of the tubercular areas occurs, followed 
by liquefaction and softening, with the formation of 
cavities of varying sizes. These later changes may first 
show themselves in the primary focus, or, when fibrosis 
has been more marked, condensation may occur without 
cavity formation; while breaking down occurs in those 
portions secondarily affected. This tendency of chronic 
pulmonary tuberculosis to necrose and form cavities has 
given it the name of clironic ulcerative tuberculosis. 
Xecrosis and softening occur especially in those cases 
in which the inflammatory changes (broncho-pneu- 
monia) have been most marked. Where fibrosis has 
predominated, the disease may present the changes that 
were described under chronic interstitial pneumonia 
(page 174). Of equal importance with the pathological 
changes and physical signs is the distribution of the 
primary foci and the manner of extension of the disease 
throughout the pulmonary system. 

"Tubercular disease, in its onward progress through 
the lung, in the majority of cases follows a distinct 
route, from which it is only turned aside by the intro- 
duction of some disturbing factor." ("Localization of 
Lesions of Phthisis," Fowler.) 

Site and Progress of Pulmonary Tuberculosis. — 
The most common point of primary infection is at 



DISEASES OF RESPIRATORY TRACT. L99 

the apex of the tipper lobe of the lun,<>\ 1 to I 1 /) inches 
below the summit. This may be either on the anterior 
or posterior border. Anteriorly, this point corresponds 
to the supraclavicular and the infraclavicular space 
opposite the middle of the clavicle, posteriorly to the 
supraspinous fossa. From this point of origin, the dis- 
ease tends to involve the upper lobe, following along the 
anterior border. Yet not infrequently the primary 
localization is on the outer portion of the upper lobe, 
corresponding to the first or second interspaces, just 
below the outer third of the clavicle — a localization 
less favorable for arrest or cure than the first. After 
involvement of one upper lobe, the secondary tubercular 
deposit may appear at the apex of the opposite lung, 
but generally there is early involvement of the upper 
portion of the lower lobe on the same side, at a point 
which corresponds to the midscapular space opposite 
the fifth dorsal spine. When the physical signs over 
the apices of the lung are doubtful, the presence of 
change in the breath sounds or the occurrence of rales 
over this position is of great diagnostic value, as it 
almost invariably indicates that the signs at the apex 
are due to tubercular changes. The base of the lower 
lobe is rarely primarily affected, so that if the respira- 
tory sounds over the apices are normal much caution 
must be exercised in pronouncing the changes that occur 
at the lower portion of the krwer lobes tubercular. 
Secondary foci in the upper portion of the lower lobe 
occur soon after primary infection of the upper lobe on 
the same side, generally extending backwards along the 
posterior surface of the lung and along the line of inter- 
lobular septa. The interlobular septa and the area of 
usual extension correspond to the lower border of the 
scapular when the arm is raised above the level of the 
clavicle, and the hand carried well over the shoulder of 
the opposite side until the finger tips rest upon the spine 
of the scapula. Extension downward generally occurs 
by the development of separate foci, and not by gradual 



2< M I THE EESPIRA TOR )' SYSTEM. 

extension from the upper portion of the lobe. Primary 
basic tuberculosis is extremely rare. In estimating the 
probability of basic lesions being tubular in origin, the 
following points must be considered: 

1. If the physical signs of the disease in the lower 
lobe are continuous from apex to base, it is probably 
tuberculosis. 

2. If the base is affected, but the upper part of the 
lower lobe is free from all change, the basic lesion is 
probably (a) non-tubercular; it may be collapse follow- 
ing bronchiectasis, catarrhal pneumonia, pneumonia or 
pleurisy. (b) "If tubular, it is secondary to some con- 
dition which has diminished the normal resisting power 
of the base, i. e., pleurisy followed by partial collapse, 
for example ; but the presumption is strongly in favor of 
non-tubercular lesion." (Fowler.) 

The apex of the opposite lung is generally involved 
after the lower lobe on the primarily affected side. The 
lesion has usually the same site as in the lobe primarily 
affected, but may be close to the interlobular septum, 
corresponding on the chest wall to the upper part of the 
axilla. The middle lobe of the right lung is rarely the 
seat of the primary lesion. It is generally affected 
rather late by extension from the upper lobe on the same 
side, and may escape entirely. 

Physical Signs. — The physical signs present in sub- 
acute and chronic pulmonary tuberculosis during the 
different stages vary with the nature of the pathological 
changes, at one time approaching those of the acute 
type, to again become less acute, closely simulating 
those of chronic bronchitis, chronic interstitial pneu- 
monia or chronic pleurisy. One of the most distinctive 
features of the physical signs of chronic pulmonary 
tuberculosis is their localization for a longer or shorter 
time, especially at the apex, and their gradual extension 
throughout the lung. This fact allows of division of 
the signs into those diagnostic of three stages of the dis- 
ease : (1) The early or incipient stage; (2) the stage 



DISEASES OF RESPIRATORY TRACT. 201 

of extension and consolidation, and (3) the stage of 
softening and excavation. These stages cannot be 
defined with positive sharpness, bill they are useful to 
indicate the nature of the preponderating pathological 
changes; and the same case may show all stages presenl 
in different portions of the lung, or even in one lobe. 

[nspection. Early or Incipient Stage. — The thorax 
over the affected area may show no change in size or 
shape, or early there may be depression of the bony 
thorax. Flattening of the upper portion of the thorax 
is suggestive of tuberculosis, especially when the flatten- 
ing is limited to one apex. Frequently it can only be 
noted when the patient is lying flat, or when looking 
down over the shoulder. 

When fibrosis and pulmonary collapse are the pre- 
dominating pathological changes, the deformity of the 
thorax is marked. There is deepening of the supra- 
and infraclavicular spaces, and retraction of the first 
and second ribs, and the clavicle becomes somewhat 
prominent. With these changes in the bony thorax, 
the expansion over the affected area is markedly dimin- 
ished, while that of the opposite side is increased. 
Pleural involvement with pain gives still further 
diminution of motion. Changes in the bony thorax 
may be entirely absent when dilatation of the air-vesicles 
(compensatory emphysema) occurs around the affected 
area. 

Second Stage. — As the disease advances, the signs 
noted by inspection are influenced by the amount of 
fibrous induration present. When this is slight, the 
chest may show very little deformity, although motion 
of the thorax may be markedly diminished. When 
fibrous thickening of the lung is marked, there is local- 
ized flattening of the chest and marked loss of expansion. 
Extension of the disease to the upper portion of the 
lower lobe causes the scapula on the affected side to 
become more prominent, while at the same time there 
may he curvature of the spine. 



202 THE RESPIRATORY SYSTEM. 

Third Stage. — With the occurrence of softening when 
the pneumonic changes have been the mosl marked feat- 
ure, with a slight amount of fibrosis, the deformity of 
the previous stage may be lessened, while at the same 

time expansion over the affected area becomes freer. 
Frequently, when the apex of one lung is in the third 
stage, with early secondary involvement of the opposite 
side, the expansion will be freer on the side first 
affected. 

In some cases marked softening with cavity forma- 
tion does not occur, being replaced by interstitial 
changes in the affected area. In these cases there is 
marked contraction of the chest, producing curvature of 
the spine. When situated in the upper portion, there 
is depression of the shoulder, with projection of the 
scapula. The intercostal spaces are depressed, and the 
ribs may overlap each other ; expansion is diminished 
or absent. When the upper lobe of the left side is 
affected, the apex beat of the heart is displaced upward 
and slightly outward, and may be seen in the third left 
interspace, or even higher. When the lower lobe of the 
left side is involved, the apex beat may be seen in the left 
axilla. Fibrosis of the right upper lobe causes the 
heart to be displaced toward the right, the apex beat 
frequently being invisible, because it is under the 
sternum. Contraction of the right lower lobe causes 
the apex beat to be seen at times beyond the right border 
of the sternum. 

Palpation Early or Incipient Stage. — It must be 
borne in mind that vocal fremitus beneath the right 
clavicle is greater than that on the left, and serves as a 
standard for comparison. If vocal fremitus is equally 
well marked on both sides, it indicates that there is 
either diminution on the right side or increase on the 
left. 

In the early stage vocal fremitus may be normal, 
increased or diminished over the affected area. It is 
normal when the lesion is deep seated and covered with 



DISEASES OF RESPIRATORY TRACT. 203 

normal lung; increased when there is inflammatory 
change or marked fibroid thickening; diminished when 
pulmonary collapse or pleuritic thickening is marked. 
Change in vocal fremitus in tuberculosis is to be taken 
in connection with the other physical signs. Palpation 
is frequently more accurate than inspection in showing 
slight change in the expansion over the apices. 

Second Stage. — With extension of the disease beyond 
the primary foci, vocal fremitus may show the same 
variations as noted during the first stage. Usually 
extension is accompanied by well-marked inflammatory 
changes in that portion of the lung that is secondarily 
affected, and there is a corresponding increase in vocal 
fremitus. Involvement of the upper portion of the 
lower lobe causes increased vocal fremitus over the 
interscapular space. Further extension over the lower 
lobe causes increased vocal fremitus in parts which are 
not contiguous. Involvement of the opposite side of 
the upper lobe may show the same changes as those that 
occur in the primary foci. 

Third Stage. — Vocal fremitus may be increased with 
the beginning of softening, due to the occurrence of 
acute exacerbations, which frequently accompany this 
change. When cavities are formed, vocal fremitus 
becomes less marked. When fibroid changes predomi- 
nate in the later stages, it may be increased. Thicken- 
ing of the pleura frequently causes diminution of vocal 
fremitus. 

Percussion. First Stage. — The percussion note 
may be unchanged, but the earliest departure from 
normal is usually a slight rise of pitch, with diminution 
of resonance. Percussion of the apex is most important. 
Percussion should be uniform and not too forcible, and 
the tissues of the thorax should be lax. The height to 
which the apex of the lung rises above the clavicle dur- 
ing inspiration and expiration should be determined, as 
diminished expansion on one or both sides is frequently 
the earliest symptom. Posteriorly, dullness on percus- 



20 1 THE RESPIRA TORY SYSTEM. 

sioiij with marked heightening of the pitch, may be 
noticed in the supraspinous region. Thickening of the 
pleura causes the note to be dull and higher pitched, 
with increased sense of resistance. 

Second Stage. — As consolidation extends, dullness 
will be detected along the edge of the sternum, and 
extending toward the axillary line. Careful percussion 
should be made at the apex and in the axilla: in all cases. 
Involvement of the upper portion of the lower lobe 
causes marked dullness in the interscapular space. 
When one apex is affected, careful examination for 
change in pulmonary resonance should be made fre- 
quently over the opposite apex. 

Third Stage. — Softening in the affected area may 
early cause a slight return of resonance, with tympanitic 
quality over the area where the percussion was dull and 
high pitched during the stage of consolidation. With 
destruction of lung tissue and the formation of a cavity, 
the percussion note becomes cavernous or amphoric, 
according to the condition of the walls of the cavity. 
Marked pleuritic thickening with fibroid change causes 
the note to become dull, with a well-marked boardy or 
wooden quality. 

Auscultation. Early or Incipient Stage. — Usually 
the earliest signs are the occurrence at the apex of fine, 
moist rales or crepitations, which are noticed during 
inspiration. These may be detected only after cough- 
ing, and may be limited to one or two rales. An impor- 
tant feature of these rales is their persistence at the 
point where first heard. Dry rales over one apex at 
times precede even moist crepitations, and are associated 
with feeble inspiratory breath sounds. These auscul- 
tatory signs generally antedate the early signs noted by 
inspection, palpation and percussion. 

The respiratory murmur may be affected in various 
ways during the incipient stage. It may be (a) feeble, 
wavy or jerky in inspiration or expiration, or in both. 
This change is p'enerallv associated with occlusion of 



nisi:. 1 8E8 OF RESPIR. I TOE V TU. 1 ( T. 205 

the bronchioles and collapse of the air-vesicles, (b) 
Wavy inspiration, with prolonged, high-pitched, slightly 
blowing expiration. This occurs when there is more 
marked increase in fibrous tissue, (c) The inspiratory 
breath sounds arc harsher, higher pitched, with slightly 
tubular quality, while the expiratory is prolonged so 
that its length equals or exceeds that of inspiration; its 
pitch is higher and its quality blowing or tubular when 
the inflammatory changes are most marked (broncho- 
pneumonia). 

It is necessary to call attention again to the normal 
breath sounds that may occur over the right apex. 
X or ma 11 v, these are sli&'htlv harsher than on the left 
side, and in certain anatomical arrangements the 
bronchi themselves may have a well-marked tubular 
quality. The relative intensity of the breath sounds on 
the two sides has the same diagnostic importance as the 
vocal fremitus. 

Second Stage. — As the disease advances, the auscul- 
tatory signs change, according to (1) the extent of 
consolidation, giving the more intense type of bronchial 
breathing; (2) whether or not there is accompanying 
bronchitis when dry and moist rales are present; (3) 
fibrosis and induration, causing marked increase in the 
length of expiration ; the bronchial element is not 
as marked, but is higher pitched than in the broncho- 
pneumonic type. (4) Thickening of the pleura causes 
various types of friction rales to be heard, with diminu- 
tion or absence of the breath sounds. (5) Compensa- 
tory distension of the lobules surrounding the affected 
area sufficient to cause the signs of consolidation to be 
masked by those of compensatory emphysema. 

Secondary involvement of the upper portion of the 
lower lobe is shown by fine rales and pleuritic crepita- 
tions, with tubular breathing in the interscapular space 
and over the hilus of the lung. The character of the 
breathing heard at this point is peculiar, on account of 
the relation of the upper portion of the lower lobe to the 
primary bronchi. 



20G THE EE8PIE. I TOE Y SYSTEM. 






Third Stage. — The occurrence of moist rales and 
their change in size when bronchitis bas been a promi- 
nent symptom are the firs! evidence of softening. At 
first these rales have, in addition to their liquid quality, 

one of sharpness, dependent upon the consolidated con- 
dition of the lung' in which they are made. But the 
conversion of the consolidated area into a cavity causes 
the breath sounds of the second st&ge to be changed in 
character. The pitch is lower, and the well-marked 
tubular quality is replaced by one of more hollow char- 
acter, cavernous or amphoric. If the cavities are dry, 
no rales may be present. If they contain fluid rales of 
large size, gurgles will be present. 

Vocal resonance over the area of softening changes 
in intensity, the broncophony and pectoriloquy of the 
stage of consolidation being replaced by amphoric or 
cavernous voice sounds. The stage of softening is 
rarely uniform throughout different portions of the 
lung, except in the more acute forms of the disease. 

ACTINOMYCOSIS. 

Infection of the lung by the ray fungus occurs gener- 
ally secondary to that of the mouth or other portions of 
the respiratory tract. Occasionally it may occur 
primarily in the lung. Clinically, two stages are recog- 
nized. 

First Stage. — This is characterized by gradual involve- 
ment of the lung and pleura. During this stage the 
physical signs are those of tuberculosis of the lung or 
emphysema, according as the pulmonary or pleural 
element is predominant. Usually the primary focus is 
at the base of the lung. 

Inspection. — Restricted motion over the lower por- 
tion of the affected side. With extensive involvement 
of the lung or pleura, there is increased bulging. 

Palpation. — As there is more or less occlusion of the 
bronchi in the affected area, vocal fremitus is dimin- 



DISEASES OF RESPIRATORY TRACT. ^ >() T 

ished. Extension to the pleura is attended with absence 
of vocal fremitus. 

Percussion. — Flatness, Avitli increased sense of 
resistance. 

Auscultation. — Feeble or absent respiratory mur- 
mur and pleuritic frictions. 

Second Stage. Inspection* — This is characterized 
by extension of the growth to the chest Avail, and the 
involvement of the various structures. There is absence 
of motion over the affected area. The intercostal spaces 
are rilled. Infiltration of the soft parts causes localized 
inflammatory signs. With necrosis of affected tissue, 
there is discharge of characteristic pus. 

Palpation. — Over the intercostal tissue there is a 
sense of hardness in the interspaces and a brawny, 
(edematous condition of the soft parts externally. With 
breaking down, before free opening occurs, fluctuation 
may be detected. 

Peecusskot. — Before the opening occurs on the sur- 
face of the chest, the signs may be that of localized 
empyema. The percussion outline does not follow that 
of effusion into the free pleural cavity, although it may 
be identical with that of localized empyema. The 
diagnosis can frequently only be made by puncture and 
microscopical examination of the fluid obtained. 

SYPHILIS OF THE LUNG. 

Syphilitic lesions of the lung may occur as (1) 
gumma, (2) broncho-pneumonia, (3) interstitial pneu- 
monia (syphilitic phthisis), (4) involvement of the 
bronchial glands and lymphatics. Destructive disease 
of the lung due to syphilis is very rare. 

The physical signs that accompany the different 
changes in the lung are closely allied to those dependent 
upon tubercular infection, and are not distinctive. 
Diagnosis depends largely upon the distribution of the 
foci and the subsequent course. 



208 



THE RESPIRATORY SYSTEM. 



Tubercular Disease. 

Pulmonary tuberculosis pri- 
marily involves tlir apex, and its 
extension throughout the lung 
follows a definite line. 

Coincident with the extension 
of the disease, softening and cav- 
ity formation occur. 

When cavities occur they tend 
to enlarge with concurrent signs 
of softening and consolidation. 

Fibrosis in pulmonary tubercu- 
losis is usually attended with 
secondary changes of consolida- 
tion and softening. 

Stenosis of the bronchi rare. 



Syphilitic Disease. 

Syphilis usually affects the 
hilus and central portion of the 
lung. 



With extension softening and 
destruction of lung tissue rarely 
occur. 

Cavities, when present are of 
the bronchiectatic type, and are 

attended with the signs described 
under bronchiectasis. 

Fibrosis excessive, distribution 
through the lung follows the line 
of lymphatics in the interlobular 
spaces. 

Stenosis of bronchi and larynx 
commonly associated with change 
in the glandular structures at the 
hilus. 



Iii many cases the differential diagnosis can be based 
only on repeated examinations of the sputum and the 
absence of tubercle bacilli, especially when signs of 
softening and bronchitis are present. 



MALIGNANT DISEASE OF THE LUNG. 

Primary involvement of the lung is rare. It is 
usually dependent upon extension from the mediastinal 
and adjacent structures or metastasis from distant por- 
tions of the body. It is especially liable to occur after 
operation on the mammary gland. 

Physical Signs. —These are variable, according to the 
site of the disease and whether the pleura is involved. 

Inspection. — When deep seated or localized, inspec- 
tion may be negative. With occlusion of a bronchus, 
localized retraction of the chest may be present. Exten- 
sion to the pleura causes marked local bulging. When 



DISEASES OF RESPIRATORY TRACT. 209 

fche entire pleural sac is involved, there is excessive 
enlargement of the affected side, exceeding that of 
effusions into the pleural cavity. 

Palpation. — Vocal fremitus is increased unless the 
growth occludes a bronchus or involves the pleural 
cavity, when it is diminished. The cardiac impulse 
may be displaced, and pulsations may be transmitted 
lli rough the new growth to abnormal areas. 

Percussion. — Change in the percussion note varies 
according to the situation of the growth and the char- 
acter of the surrounding tissue. 

Auscultation. — The sounds are those of consolida- 
tion, pulmonary collapse or thickening of the pleural 
sac. When extension to the lung is secondary to 
mediastinal involvement, pressure symptoms are 
present. 

PLEURISY. 

Pleurisy is an inflammation of the serous membrane, 
characterized by an exudation upon the free surface of 
the pleura, which may be fibrinous, serous, sero-fibrin- 
ous, sero-purulent, purulent or hemorrhagic. All 
these varieties of exudation may occur at different 
stages of the same case of pleurisy. The inflammation 
may not be attended with an exudation upon the free 
surface, but characterized by a fibrous thickening. 
Inflammations of the pleura may be acute or chronic, 
general or localized, primary or secondary. Numerous 
classifications or subdivisions of pleurisy have been 
made. For physical diagnosis three forms are suffi- 
cient, depending upon the character and amount of the 
exudation and the changes produced in the pleura : 
(1) Dry pleurisy with fibrinous exudate; (2) pleurisy 
with effusion, and (3) chronic pleurisy with adhesions. 

(1) Dry Pleurisy. — Before the exudation appears the 
pleural surface undergoes certain changes, which may 
give quite distinctive physical signs. The normal 
14 



210 THE RESPIRATORY SYSTEM. 

moist condition of the pleural surface is lacking. The 
surfaces becomes dry; there is loss of lining endothe- 
lium, with more or less roughening of the pleural sue. 
When exudation lakes place, the pleural surface- are 
more or less thickly coated with fibrinous material, 
which, while allowing a certain amount* of movement 
between the two pleural surfaces, causes thickening of 
the pleura] sac and the occurrence of physical signs. 

(2) Pleurisy with Effusion. — This form includes sero- 
fibrinous pleurisy, subacute pleurisy, chronic pleurisy 
with effusion, empyema. The nature of the fluid does 
not modify the physical signs. The physical signs that 
are present with effusion into the pleural cavity are 
dependent upon the presence of the fluid and the effects 
that it produces upon the lung, heart, position of the 
diaphragm and abdominal viscera and in the thoracic 
walls. Normally the pleural surfaces are in apposition 
throughout. They are kept together by atmospheric 
pressure, although the elasticity of the lung on the one 
side and that of the thorax on the other produces a con- 
stant traction on the two pleural surfaces, which tends 
to separate them. When fluid or air is present in the 
pleural cavity, certain changes occur : (a) The two 
surfaces of the pleura are separated: (b) the distension 
of the pleural sac diminishes the space to be filled by the 
lung; (c) the elasticity of the lung causes it to retract 
and to exert traction or lifting power on the fluid. 
Until a certain point is reached, the fluid exercises no 
compressing action on the lung, which retracts before 
the fluid until its elasticity is satisfied. After this point 
has been reached, the fluid causes compression of the 
lung. (d) With the filling in of the pleura there is loss 
of tension in the pulmonary tissue, producing change in 
the percussion note, (e) The chest walls, relieved from 
the pulling action of the lung, assume the position of 
elastic equilibrium, changing the contour of that side 
of the thorax. The diaphragm, unacted upon by the 
lung, does not rise as high in the thorax ; later on the 



DISEASES OF RESPIRATORY TRACT. 21 1 

weight of the fluid causes it to descend si ill lower. 
(f) The opposite lung is also influenced by the change 
in the interthoracic pressure, and tends to contract and 

draw the heart and mediastinum towards the unaffected 
side. Gradually, with the accumulation of fluid, 
the normal interthoracic negative pressure diminishes 
to zero, and later may be replaced by positive pressure. 
As long as a negative pressure is present in the chest, 
it exercises an action upon the fluid. As the fluid 
increases the negative pressure becomes less marked, 
and later the weight of the liquid itself exerts a positive 
pressure, causing bulging of the intercostal spaces, com- 
pression of the lung, depression of the diaphragm, dis- 
placement of the heart and interference with return 
circulation. As the negative pressure depends upon 
the elasticity of the lung, the occurrence of signs indi- 
cating change from negative to positive pressure is an 
index of the elasticity of the lung when taken in con- 
nection with amount of expansion. 

(3) Chronic Pleurisy with Adhesion. — In chronic 
pleurisy with adhesion, more or less fluid may be 
present, but usually, the most marked pathological 
change is fibrous thickening of the pleura with 
adhesions, binding together the two surfaces of the sac. 
The effect of thickening of the pleura is to interfere 
with expansion of the lung and to prevent free move- 
ment of the thorax. When these changes are localized, 
their effects are limited to the area involved, causing 
many of the thoracic deformities and interference with 
respiratory movements noted under "Inspection" and 
"Palpation." Thickening of the pleura, with imperfect 
expansion of the pulmonary tissue, causes change in the 
percussion note. As explained under "Auscultation," 
imperfect expansion of the lung causes diminution or 
absence of the normal breath sounds. Localized 
adhesive pleurisy occurs early in pulmonary tubercu- 
losis, and modifies the physical signs of that condition. 

Physical Signs. Inspection. 1. Dry Pleurisy. — 



212 THE RESPIBATOBY SYSTEM. 

When pain is present, the patient leans to the affected 
side, or lies on that side to prevent motion. Expansion 
is restricted, and motion is short and jerky. Movement 
over opposite lung is exaggerated. 

2. Pleurisy with Effusion. — When effusion, either 
fibrinous or serous, is sufficient to separate the two sur- 
faces, with absence of pain, motion over the affected side 
may be freer. With the occurrence of liquid effusion, 
there is slight enlargement of the lower portion of the 
thorax. As effusion increases, the contour of the side 
becomes more rounded, with widening of the intercostal 
spaces. With complete filling of the pleural sac, the side 
is enlarged in all directions. The spine is slightly 
curved toward the affected side ; the intercostal spaces 
are obliterated, and the chest appears smooth. Motion 
becomes progressively less until, with full distension, it 
is absent. When positive pressure occurs within the 
pleural sac, there is bulging of the intercostal spaces, 
and pulsations may be present. The opposite side is in 
a state of compensatory emphysema, and the respiratory 
movements are exaggerated. Cardiac displacement 
occurs early unless prevented by adhesions or conditions 
causing fixation of the mediastinum. With absorption 
of the fluid or with its withdrawal, the chest returns 
gradually to its normal contour, with increase of the 
respiratory movements. 

3. Pleurisy ivith Adhesion. — The occurrence of 
pleural thickening or adhesions causes movement to be 
restricted, followed by retraction of chest walls on the 
affected side if pulmonary expansion is prevented. 
These changes are especially marked over the base of the 
lung. 

Palpation. 1. Dry Pleurisy. — Vocal fremitus may 
be normal. When the fibrinous exudate is thick, vocal 
fremitus may be diminished or absent. Slight friction 
fremitus may be detected. 

2. Pleurisy ivith Effusion. — With the occurrence of 
effusion, there is gradual loss of vocal fremitus, occur- 



DISEASES OF EESP1RA TOR V Til. 1 ( T. 21 3 

ring first in the Lower portion of the pleural sac 
posteriorly, and gradually advancing upward as the sac 
becomes filled. When the fluid has reached a certain 
amount, vocal fremitus is usually increased at the upper 
level. Vocal fremitus over the upper lobe of the lung 
may be normal. With extensive effusion, relaxation 
of the lung causes absence of vocal fremitus over the 
upper lobe also. Compression of the lung causes 
increased vocal fremitus posteriorly along the spine. 
Vocal fremitus may be detected over the site of the 
fluid when adhesions bind the lung to the chest wall 
and prevent its retraction. The degree of cardiac dis- 
placement may be estimated more definitely by palpa- 
tion than by inspection. Displacement of the liver 
below the free border of the ribs occurs when the effusion 
is large, or when retraction of the lung or loss of 
elasticity cause the fluid to act upon the diaphragm 
early. 

3. Pleurisy with Adhesion. — Pleuritic thickening, 
besides interfering with respiratory movements, causes 
diminution of vocal fremitus ; and these, when asso- 
ciated with fibrous induration of the lung, may cause 
increased vocal fremitus. 

Percussion. 1. Dry Pleurisy. — With a slight 
fibrinous layer, there is little or no change in resonance. 
If exudation is very abundant, there is loss of resonance, 
with increased sense of resistance. 

2. Pleurisy with Effusion. — With the occurrence of 
effusion, the earliest indications are shown by flatness 
at the base of the lung posteriorly. Slight effusion 
causes the area of flatness to be widest along the spine, 
sloping in a gentle curve toward the axilla. With 
increase of fluid, the line of dullness extends beyond 
the axilla to the mammary line. When the fluid is 
sufficient to reach the angle of the scapula, the percus- 
sion outline shows a more or less curved line, which has 
been called the "curved line of Ellis." 

The fluid rises highest in the axilla, and on the 



214 



THE RESPIRATORY SYSTEM. 



anterior border of the chesl the line curves slightly 
downward toward the sternum, while posteriorly the 
line descends more abruptly to the spine. Percussion 
of the affected side at this stage shows three zones: 
(1) Flatness over the fluid ; (2) posteriorly, dullness over 

Fig. 27. 




Lines 1, 2. 3, curve of small effusion. 

4. 5. 6, 7. curved line of Ellis (letter of S). 
Dotted line from summit of curve to spine, upper limit of dull triangle. 

the triangular space, hounded above by a line drawn 
horizontally from the apex of the line of flatness in the 
axilla. Above the horizontal line pulmonary resonance 
of low pitch, with faint tympanitic quality, may be 
detected. (3) On the anterior portion of the chest. 



DISEASES OF RESPIRATORY TRACT. 215 

between the horizontal line and the line of flatness, per- 
cussion gives a peculiar tympanitic quality — Skoda's 
resonance. ( Figs. 27 and 28.) 

As the fluid increases in amount and the elasticity of 
the lung is satisfied, the fluid assumes a more horizontal 
line, and at last, when negative pressure lias been 
replaced by positive (which generally occurs when the 

Fig. 28. 




Dotted line showing position of heart, according to amount of effusion. 

fluid reaches the level of the third rib), the lung is com- 
pressed by the fluid, and a small area of tympanitic 
percussion may be detected anteriorly under the clavi- 
cles, close to the sternum, and in the supraspinous fossa 
behind. 

As the curved outline of the fluid depends upon the 
elasticity of the lung, a more nearly horizontal line, 



210 Till: RE8PIR. ! TOR V SYSTEM. 

with a small amount of effusion, shows thai there is loss 
of pulmonary elasticity or that the lung is prevented 
from retraction by adhesions, or that there is consolida- 
tion ( probably tubercular) at the apex. The position of 
the line of fluid does not change readily with change in 
posture of the patient. When the patient has long 
occupied the recumbent posture, the line of Ellis is more 
or less displaced by the fluid gravitating toward the most 
dependent portion. 

3. Pleurisy with Adhesion. — Fibrous thickening of 
the pleura with adhesions causes the percussion note to 
be impaired over the lower portion of the lung, and is 
usually associated with retraction of the bony thorax. 

Auscultation. 1. Dry Pleurisy. — The respiratory 
murmur is jerky and partly suppressed ; inspiration is 
shortened, with expiration prolonged, slow and feeble, 
During the early stage the dry, rubbing friction sounds, 
similar to the sound made when two rough surfaces of 
paper are rubbed together, or when the hand is rubbed 
over the ear, are heard. With the occurrence of plastic 
exudation, the character of the friction sounds change. 
They become stickier, are superficial, and later may 
have a fine, grazing character. They are most abun- 
dant at the end of inspiration and the beginning of 
expiration. They may be absent in quiet breathing, and 
only be detected at the end of a deep inspiration. When 
the pleurisy of the left side involves the portion over- 
lying the prseeordia, friction rales may be heard 
synchronously with the heart sounds. 

2. Pleurisy with Effusion. — The auscultatory signs 
are variable. The signs typical of effusion of small 
amount are slight diminution or absence of breath 
sounds at base of lung and distant voice sounds. As the 
fluid increases in amount, there is absence of breath 
sounds over the lower portion of the thorax correspond- 
ing to the line of percussion flatness. At the level of 
the fluid vesicular murmur may be faintly heard, asso- 
ciated with bronchial breathing of a peculiar blowing, 



DISEASES OF RESPIRATORY TRACT. 217 

wavy character. The voice sounds are also of a wavy, 
nasal character (segophony). At the upper portion of 
the thorax, oven* the apex of the lung, vesicular murmur 
may be normal or slightly exaggerated. In large 
effusions at the upper level, bronchial breathing becomes 
more intense, and bronchophony and pectoriloquy are 
present. 

Occasionally tubular or bronchial breathing, broncho- 
phony and pectoriloquy are heard over the fluid, simu- 
lating the auscultatory signs heard in pneumonia. 
These signs are especially apt to occur in children ; also 
when bands of adhesion prevent the lung from retract- 
ing as the fluid accumulates, so that it is compressed 
posteriorly along the spine. The sound is conducted bv 
the tense bands of adhesion through the fluid to the 
bony thorax. Small consolidation of the lower lobes of 
the lung may also cause bronchial breathing to be 
present below the level of the fluid. 

In addition to displacement of the heart, a soft, sys- 
tolic murmur is detected over the precordial space when 
the effusion is sufficiently large to cause pressure upon 
the mediastinum or slight distortion of the large vessels. 
With disappearance of the fluid, the breath sounds 
return, and pleuritic frictions are heard above the level 
of the fluid. 

3. Pleurisy with Adhesion. — Pleuritic thickening 
with adhesion causes absence or diminution of the 
breath sounds, with friction fremitus of a rough, rasp- 
ing or creaking character. Intercurrent attacks of 
acute pleurisy may reinduce the signs of fibrinous 
exudation and of effusion. 

Differential Diagnosis. Pleurodynia. — Inspection and 
palpation may be identical. Percussion shows no 
change in resonance. On auscultation there are present 
feeble breath sounds, due to loss of expansion of the 
thorax, but unattended with friction rales. 

Hydatid of the Pleura. — This may begin at the base 
of the lung, but rarely gives a line of dullness so 



2 1 8 THE BESPIRA TOR V SYSTEM. 

symmetrical as that of pleurisy with effusion. Usually 
the area of percussion flatness is more nearly circular, 
with resonance on either side, which may have a more 
or less tympanitic quality. Displacement of the heart 
and abdominal viscera does not occur unless the cyst is 
large. Over the cyst localized bulging of the chest wall 
is very marked. The differential diagnosis by physical 
signs between encapsulated pleurisy and hydatid cyst 
is almost impossible. 

Pneumonia. ( See page 1 72. ) 

Sub-Diaphragmatic Abscess. Inspection. — Change in 
the size and contour of the chest is most marked over the 
free ribs extending to the hypochondrium. 

Pai^atiox. — Absence of vocal fremitus over lower 
portion of thorax, associated with rigidity of hypochon- 
driac region and marked depression of liver. 

Percussion. — Upper line of flatness is high in axilla, 
but does not conform to that of pleurisy with effusion at 
the same level. Absence of dull area behind. Skoda's 
resonance may be detected anteriorly. Displacement of 
the heart does not occur. Slight displacement upward 
of the diaphragm. The apex of the diaphragm is 
higher than normal. On examination with the X ray 
the difference between subdiaphragmatic and supra- 
diaphragmatic conditions is well marked. 

HYDROTHORAX. 

This condition differs from pleurisy with effusion in 
that it is not inflammatory, but due to simple dropsi- 
cal effusion into the pleural cavity. When limited to 
one side, the physical signs are identical with those of 
the inflammatory type. Usually both sides are involved, 
and the following physical signs are present : 

Inspection. — Slight motion on both sides. Slight 
enlargement over lower portion of thorax. 

Palpatiox. — Vocal fremitus is most marked poste- 
riorly. Heart is displaced upward. 



DISEASES OF RESPIRATORY TRACT. 219 

Percussion. — Flatness over lower portion of thorax. 
Line of flatness does not follow markedly the curve 
noted under unilateral affections. Above the level of 
the fluid Skoda's resonance is early present, with hyper- 
resonance at the apex. 

Auscultation. — Absence of breath sounds at the 
base, below the level of the fluid. Bronchial breathing 
at the upper level. Fine, moist rales are heard in the 
rest of the lungs if pulmonary oedema is present. 



PNEUMOTHORAX. HYDRO -PNEUMOTHORAX. 

Due to the presence of air or air and fluid in the 
pleural cavity. 

Physical Signs. Inspection. — Enlargement more 
marked than in pleurisy with effusion. Loss of motion 
complete. 

Palpation. — Absence of vocal fremitus. In hydro- 
or pyo-pneumothorax succussion fremitus (splashing 
sounds) is present when the patient is shaken or on 
violent coughing. 

Percussion. — Pneumothorax ; increased resonance 
over affected side. When fluid and air are present in 
the pleural cavity, two zones of resonance are detected — 
flatness below the level of the fluid, and increased reso- 
nance with a tympanitic quality above it. The line of 
flatness is horizontal. When the anterior portion of the 
chest is percussed with two coins while the observer 
listens behind, a peculiar ringing, metallic sound is 
heard (coin test). 

Auscultation. — In pneumothorax there may be 
absence of all respiratory sounds over the affected side. 
When an opening exists between the bronchial tract and 
pleural cavity, a peculiar, intense, amphoric breathing 
is heard (lung fistula sound). When fluid and air are 
both contained in the pleural cavity, by shaking the 
patient, or after coughing, succussion sounds are pro- 



220 THE EE8PIEA TOE Y SYSTEM. 

duced. Tho falling of drops of secretion from the 
upper portion of the cavity into the fluid below gives a 
peculiar echo-like sound (metallic tinkles). 



PART III. 
THE CIRCULATORY SYSTEM, 



CHAP TEE VIII. 

INSPECTION. 

Inspection of the circulatory system embraces not 
only the heart, but also all of those phenomena which 
depend upon cardiac action. It includes the contour of 
the precordial area, the visible cardiac movements as 
shown by the apex beat, the pulsations of the arterial 
and venous systems, respiratory movements (dyspnoea), 
color of the skin and mucous membrane, and oedema of 
the cellular tissue. 

For examination, the patient's clothing should be 
removed, so that a free view of the anterior portion at 
least of the chest, may be obtained. The patient should 
be examined in both direct and oblique light, and in the 
standing and recumbent postures. The examiner 
should view the surface from directly in front and after- 
wards obliquely, so as to note all cardiac movements. 

The circulatory movements may be seen more 
clearly by placing over the seat of motion a piece of 
adhesive plaster through which a pin has been stuck, 
and applying to this pin a piece of cotton or lint as a 
flag. Or small cones of paper or bits of cotton wool 
may be stuck to the chest wall with mucilage or oint- 
ment. The object of this is to increase the area of 



222 THE CIB( 7 LA TOE )' SYSTEM. 

motion as soon a1 the extremity of the pin or paper cone, 
and to determine whether or not the movement is 

expansile. This latter condition is best soon by plac- 
ing over the area a piece of rubber plaster with a slit 
cut through it; this will show increase in size by widen- 
ing- of the opening. 

Data obtained by inspection must be verified and cor- 
rected by the knowledge obtained by the other methods 
of examination. 

Normally, that portion of the thorax which is known 
as the prsecordia shows a slight flattening surrounded by 
a slight elevation of the ribs. 

In the fifth intercostal space, 2% to 3 inches to the 
left of the sternum, at a point where a line drawn 2 
inches from the left edge of the sternum and 1 inch 
inside the nipple line bisects the space, is seen a local- 
ized, rhythmical impulse occupying an area of about 
1 inch square. 

THE APEX BEAT. 

This is due to the impact of the heart near the 
anatomical apex on the chest wall. It does not mark, 
as is commonly supposed, the true anatomical apex, but 
that part which strikes the chest wall is distant from 
the true apex about three-quarters of an inch. 

The cardiac impulse is due to change in form of the 
heart during systole, the vertical diameter being length- 
ened, with a corresponding shortening of the transverse. 

The site of the apex beat varies normally within cer- 
tain limits. In the child it is higher, being found in the 
fourth interspace, and farther from the mediastinum. 
In old age it is lower down, being in the sixth inter- 
space, nearer the median line. In persons with short, 
broad thoraces it is found slightly above the fifth inter- 
space, while in those in whom the thorax is narrow it 
may be found underneath the sixth rib. and even at the 
upper border of the sixth interspace. The site of the 



INSPECTION. 223 

apex beat also varies with the position of the patient. 
When lying on the Left side, it is carried to the left as 
far as the midclavicular line, and even further; when 
the patient is lying en the right side, it is carried inward 
toward the sternum, but its mobility is not as much 
as when the patient is lying on the left side. The 
respiratory act also causes a slight change in the loca- 
tion of the apex beat. In quiet respirations it is but 
little changed. In forced inspiration it is carried down- 
ward and toward the median line, while in forced 
expiration it is displaced upward and slightly to the left. 

Changes in the Praecordia. — The bony thorax over the 
cardiac area may bulge from the third to the seventh rib, 
ami from the sternum to the left nipple; or the projec- 
tion may extend from nipple to nipple. The bulging 
and distortion of the precordial area may be caused by 
conditions not associated with cardiac or circulatory dis- 
eases : (a) Swelling of the cellular tissue, due to 
inflammatory exudation or to localized deposits of 
adipose tissue ; (b) changes in the bony thorax de- 
pendent upon rickets ; (c) a bulging anteriorly, with a 
compensating posterior curve from spinal curvature. 

Local bulgings over the praeeordium may be caused 
by cardiac changes, although they are not marked unless 
the cardiac disease occurred in early life, when the 
flexibility of the bones permitted easy distortion, 
(a) Cardiac hypertrophy and dilatation do not pro- 
duce marked change in the precordial area unless it has 
occurred early in life, when it may produce a distinct 
forward bulging of the sternum and ribs, especially of 
the left side. Congenital cardiac disease produces the 
most marked distortion of the thorax. The amount of 
deformity in the case of chronic hypertrophy with dila- 
tation is important in estimating the time of life at 
which the cardiac disease occurred, (b) Pericarditis 
causes the contour of the praeeordium to be rounded, the 
normal slight flatness being absent. The interspaces 
are wider than normal, being even with the surface of 



224 THE CIRCULATORY SYSTEM. 

the ribs or bulging, according to the amount of exuda- 
tion into the pericardia] sue. The amount of bulging 
that is present in the case of pericarditis with effusion 
depends upon the flexibility of the bony thorax; it is 
marked in childhood, and scarcely noticeable or absent 
when ossification of the ribs has taken place 1 . 

Aneurism at different portions of the thoracic artery 
may produce local bulgings, as Avill be described later. 

Permanent retraction of the bony thorax does not 
occur as the result of cardiac disease unless associated 
with other changes in the thoracic viscera. 

Conditions Modifying the Location, Extent and Character 
of the Apex Beat. — As lias already been stated, the 
visible apex beat merely marks the point at which some 
portion of the heart near the anatomical apex strikes 
the chest wall. The portion of the heart which gives 
the impulse is generally the right ventricle, about three- 
quarters of an inch from the true apex. The point of 
contact of the heart may vary within wide limits, due to 
changes in the relation of the heart to the chest wall, so 
that the visible apex beat is changed from the normal in 
location, extent and character. 

Influence of the Soft Parts. — The apex beat is much 
more noticeable and the exact point of contact more 
distinct in thin persons, especially those with flexible 
thoraces. In persons where the prsecordia is thickly 
covered with adipose tissue the area of impulse will be 
slightly increased, while the point of the apex beat will 
be less distinct. This is especially marked in cases 
where the mamma is full and tense, the cardiac impulse 
being conveyed to the entire breast and the apex beat 
being masked. Where the mamma is large and flaccid, 
the apex beat may be entirely absent. 

Influence of the Bony Thorax. — The elasticity and 
mobility of the ribs influence largely the character of 
the apex beat. In children, where there is marked 
depression of the thorax during expiration, the apex 
beat is distinct and more extensive. In old age the 



INSPECTION. 225 

rigidity of the thorax and secondary changes in the lung 
cause the apex to become indistinct or absent. Narrow 
intercostal spaces may render the apex beat invisible, 
the heart striking the chest immediately under the rib. 
In very broad thoraces the apex beat is higher, being 
underneath the fifth rib, or even in the fourth interspace. 
In long, narrow thoraces the apex beat is lower, being 
displaced downward and slightly outward. The flat, 
rachitic or paralytic thorax, with narrow anteroposte- 
rior diameter at the lower portion of the preecordium, 
brings the apex beat further to the left in the fifth inter- 
space. The pigeon-shaped thorax, with increase in the 
anteroposterior diameter, causes the apex beat to be 
nearer the median line and somewhat indistinct, except 
where the depression beyond the bulging causes the true 
apex to strike the chest wall. 

When the ribs over the cardiac region are displaced 
by primary disease of the lungs, the apex beat is dis- 
placed to the right or left and upwards or downward, 
according to the pulmonary condition. 

Influence of Diseases of the Pleura. — Filling of the 
pleural sac with air or fluid causes displacement of the 
heart to the opposite side and alters its relation to the 
chest wall, unless the movement of the heart is prevented 
by adhesions. 

Effusions into the right pleural sac cause the heart to 
be displaced to the left and upward, the apex beat being 
seen in the mid-axillary line. The base of the heart is 
also displaced, but not to the same degree as the apex. 

Effusions into the left pleural sac move the heart 
toward the right, so that, according to the amount of 
fluid present, the apex beat may be felt at any point 
between the normal site and the right mammillary line. 
As was noted under "Pleurisy with Effusion" (page 
215), displacement of the heart is one of the most char- 
acteristic signs of this condition. Occasionally the 
cardiac impulse is transmitted to the fluid, giving the 
physical signs of pulsating empyema. 
15 



226 rui: < inn rLA tor y SYSTEM. 

Adhesions of the pleural surface and contractions 
draw the heart toward the affected side, with displace- 
ment of the apex beat. This will be fully explained 
later on. 

Influence of Changes in the Lung. — Quiet breathing 
produces no change in the apex beat. Full, deep in- 
spiration causes the inflated lung to cover the heart to a 
greater degree, thus lessening the extent and force of 
the apex beat, and may cause it to disappear entirely. 
Frequently it is sufficient to displace it downward, so 
that it is seen an interspace lower. 

Permanent increase in size of the lungs, as in general 
emphysema, causes marked change in the relation of the 
heart to the bony thorax. As a result of the increase in 
size of the lungs and loss of tension, as was explained 
under "Emphysema/ 5 there is elevation of the ribs and 
depression of the diaphragm, which also depresses the 
heart, the apex beat being carried inward and down- 
ward. When increase in size of the lung is associated 
with obstruction of the circulation, the hypertrophy and 
dilatation of the right ventricle increase the pulsation 
in area and extent, and carry it still lower, giving 
epigastric pulsation. 

Unilateral emphysema causes the heart to be dis- 
placed similarly to the manner seen in pleurisy. Com- 
pensatory emphysema in the right lung carries the apex 
beat to the left and higher. Emphysema of the left 
lung causes it to be lower, and rarely displaces it beyond 
the left sternal line. 

Shrinkage of the lung as a result of pleurisy, or due 
to interstitial change in the pulmonary tissue (as in 
interstitial pneumonia and fibroid phthisis), draws the 
heart toward the diseased side. When the changes are 
limited to the lower border of the left lung, that portion 
of the heart which is normally covered by pulmonary 
tissue may be brought into direct contact with the chest 
wall ; the visible apex beat will be increased in area and 
carried horizontally to the left, and a greater portion of 



INSPECTION. 227 

the heart, including the true apex, strikes the chest wall. 

When the change is more extensive, the heart may he 
drawn upward and outward, the apex beat being seen in 
the mid-axillary line. When the right lung is affected, 
the heart is drawn to the right side and upward. 
Involvement of the upper portion of the lung may 
cause visible pulsations of the pulmonary artery in the 
second left interspace, or it may be so extensive that the 
phases of cardiac movement, systole, diastole and the 
pre-systolic contraction of the auricle may be seen over 
the entire pra?cordial space, giving the impression of a 
peristaltic wave. 

Influence of Changes in the Pericardium. — Effusion into 
the pericardium causes change in the site and area of 
the apex beat, according to the character and amount of 
exudation. In small effusions the apex beat may be 
seen over a wider area, especially toward the epigas- 
trium. When the pericardium is filled to a greater 
degree, the visible apex beat is carried upward into the 
fourth interspace or higher, due to a portion of the heart 
higher up striking the chest wall, and not to an upward 
displacement of the true apex. When the pericardium 
is fully distended with fluid, the apex beat may be 
absent. 

Adhesions of the pericardium to the pleura or medias- 
tinum may cause retraction of the chest wall over the 
apex (Broadbent's sign). Retraction of the chest wall 
over the precordial area is one of the diagnostic signs of 
adhesions of the pericardium when it produces marked 
visible recession of the costal cartilages, ribs and 
sternum, and is associated with signs of cardiac hyper- 
trophy greater than the amount of cardiac valvular dis- 
ease would produce, and where there is also evidence 
of a co-existing pleurisy or exo-cardial disease. 

Retraction of the chest wall over the apex also occurs 
with adherent pericardium, secondary to pulmonary 
tuberculosis. 

Influence of Changes in the Heart. — The site, extent 



228 THE CIECULA TOR V SYSTEM. 

and character of the apex beat corresponds, within cer- 
tain limits, to the extent of the cardiac changes. 
Powerful action of the heart, due to physical exertion 
or mental excitement, as in Grave's disease, in poisoning 

and in fever, causes the apex beat to he more noticeable 
and broader by causing a larger area of the chest wall 
to be affected. 

In a similar manner, simple hypertrophy of the left 
ventricle causes the apex beat to be carried to the left 
and very slightly downward. Increase in the size and 
force of the left ventricle causes a portion of the heart 
closer to the true apex to strike the chest wall, and the 
beat is strong, distinct and defined. When the left 
ventricle is both dilated and hypertrophied, the apex 
beat is carried downward and to the left, being seen in 
the eighth interspace or lower. The impulse is in pro- 
portion to the amount of hypertrophy; the apex beat 
will be correspondingly strong, a large area of the chest 
wall will be influenced and the impulse, though wide, 
will be well defined. 

When dilatation is the most marked feature, the apex 
beat will be weak and diffused. 

Eight-sided cardiac hypertrophy causes the visible 
pulsation to appear between the ensiform cartilage and 
the normal position of the apex beat in the fifth inter- 
space. The apex beat may be carried slightly to the 
left, but rarely goes beyond the left mammary line. 
When the hypertrophy of the right ventricle is extensive 
and associated with dilatation, pulsation may be seen in 
the third, fourth, fifth, sixth and even seventh inter- 
space near the termination of the cartilages on the left 
side of the sternum, or in the epigastrium, along the 
free border of the ribs on the left side. 

When dilatation of the right ventricle is extensive, 
with slight hypertrophy, the area of pulsation is more 
extended, and the character of the impulse is more 
diffused. 

Dilatation of the right auricle may cause pulsation 



INSPECTION, 229 

to be seen in the fifth right interspace along the 
sternum. Pulsation of the conns arteriosus and hyper- 
trophy and dilatation of the right ventricle may produce 

pulsations in the second and third interspaces on the left 
side. 

Cardiac weakness from any cause, as myocarditis, 
fatty heart, degenerations, etc., causes the apex beat to 
be less noticeable or entirely absent. 

In congenital transpositions of the organs the apex 
beat is found to the right side of the fifth interspace, 
and has the characteristics of that noted in the normal 
heart. 

Influence of Changes in the Mediastinum. — Aneurism of 
that portion of the aorta contained in the mediastinum, 
abscesses, new growths and enlarged glands displace the 
apex beat downward and to the left. Fibrinous medias- 
tinals with contraction may bind the heart down and 
cause retraction of the precordial area during systole. 

Influence of Abdominal Changes. — Pressure from below 
the diaphragm, due to ascites, meteor ism, tumors or 
anything that increases the contents or the abdominal 
pressure forces up the diaphragm, causing the heart 
to be displaced upward and the apex beat to be seen in 
the fourth interspace to the left. 

Displacement of the diaphragm downward, as occurs 
in ptosis of the abdominal organs, etc., carries the apex 
downward, and the impulse is seen in the epigastric 
region only. 

IMPULSES DUE TO CHANGES IN BLOOD-VESSELS. 

Aneurism of the thoracic aorta may produce visible 
pulsations in different portions of the thorax. When it 
involves the ascending portion, the pulsation is seen to 
the right of the sternum. When the transverse portion 
is involved, the impulse may be conveyed to the sternum 
itself and upward, and be seen also in the episternal 
notch. Aneurism of the descending aorta, when 



230 THE CIRCl 'LA TOR ¥ SYSTEM. 

developing forward, shows the impulse to the left of the 
sternum. 

Arterial Pulsations. — Normally, the only pulsation that 
is seen in the arteries is a slight movement in the caro- 
tids just above the clavicles. 

Conditions Causing Visible Pulsations in the Arteries. 
(1) Cardiac Causes. — When cardiac action is sudden 
and forcible, as occurs in exercise and under mental 
excitement, the blood is forced into the aorta and larger 
blood-vessels with sufficient force to cause a marked 
visible pulsation. 

(2) Vascular Causes. — When the blood is forced 
from the heart into the blood-vessels that are only par- 
tially filled, instead of the normal pulse wave being 
transmitted through the blood-vessels, there is a direct 
propulsion of the blood wave through the aorta into the 
blood-vessels themselves. This condition of the blood- 
vessels occurs (a) whenever there is a rapid emptying of 
the larger blood-vessels into the capillaries and veins, as 
occurs in vaso-motor loss of control, in Grave's disease, 
chlorosis and anaemia ; (b) when the aorta, during 
diastole, empties itself into the enlarged ventricle 
(aortic regurgitation), and with the following systole 
there is a sudden forcing of a large amount of blood into 
the partially empty and collapsed aorta and its branches. 
In aortic regurgitation the visible systolic pulsation may 
be seen over the entire body. Arterial pulsation is also 
seen when the blood-vessels have been converted from 
elastic, distensible tubes into rigid ones. Normally, 
with each systole there is dilatation of the aorta, and 
during diastole the elasticity of the large vessels forces 
the blood onward. When the aorta is converted into a 
rigid tube, with each systole the heart impulse is con- 
veyed to the entire arterial tract, producing visible 
movement in the blood-vessels. 

Capillary Pulse. — Occasionally in aortic regurgitation 
systolic, rhythmical pulsations are seen in the capil- 
laries; with loss of cardiac power these pulsations dis- 



INSPECTION. 2ol 

appear. Capillary pulse may be observed by friction of 
the surface, producing dilatation of the superficial 
blood-vessels by placing a slide on the mucous mem- 
brane of the lips and with slight pressure causing the 
capillaries alone to be seen. 

Venous Pulsation. — Slight pulsations may be seen in 
the neck during health, but are most marked in the 
subjects of chlorosis and anaemia. In order to see them, 
the patient should be recumbent, the head thrown 
slightly backward and the light should fall across the 
root of the neck obliquely. The physician should view 
the neck at a slightly higher level. 

The normal venous pulsations are usually a gradual, 
general dilation of the blood-vessel. "The wave is 
longer, broader and less sudden in its oscillation than 
that seen in the artery. It is more influenced by 
posture, being greatest when the patient is lying flat. It 
is presystolic, occurring before that of the carotid ; the 
collapse of the vein corresponds to the apex beat." 

In chlorosis and anaemia this presystolic venous pulsa- 
tion may be markedly increased. The abnormal 
pulsations seen in the veins are systolic in time. They 
are most marked in the veins of the right side, and are 
best looked for in the external jugulars just above the 
clavicle, outside of the border of the sternocleido- 
mastoid muscle, as at this point the vein is unaccom- 
panied by the artery. 

It is necessary to determine whether or not the sys- 
tolic pulsation in the vein is due to the impulse con- 
veyed to the vein from a distance. (1) If slight, slow 
pressure over the vein at the lowest point stops the pulsa- 
tion, it shows that it is a true venous pulsation. Such a 
light pressure would not influence pulsations transmitted 
from the artery. (2) By drawing the finger upward 
along the course of the vein, and keeping it at the upper 
level, the vein will fill from below and the pulsation will 
be systolic. Sudden emptying of the vein during 
diastole is said to be a sign of adherent pericardium, 
but this is a doubtful sim. 



232 THE CIRCULATORY SYSTEM. 

Pulsation in the peripheral veins may be due (a) to 
aortic regurgitation; (b) certain etages of fever, and 

is made more visible by putting a thin layer of sealing- 
wax over the vein. 

Cardiac Dyspnoea. — Cardiac dyspnoea differs from pul- 
monary dyspnoea in the following respects: (1) While 
the patient is at rest the respiratory movements are 
normal, but the slightest exertion induces an intense 
feeling of oppression and dyspnoea. (2) Examination 
of the lung sIioavs no interference with the entrance and 
exit of air; respiratory movements are increased in 
force, frequency and extent without the other evidences 
of interference in the respiratory tract. (3) The 
dyspnoea is out of all proportion to the lesion that may 
have been induced secondarily in the lung by the cardiac 
disease. 

Types of Cardiac Dyspncea. — (1) Dyspnoea on 
exertion, (2) paroxysmal dyspnoea, occurring when at 
rest, especially when the patient wakes out of sleep, due 
to sudden raising of the blood pressure; (3) chronic 
dyspnoea or orthopnoea, (4) rhythmical dyspnoea 
( Cheyne-Stokes respiration). 

Dropsy. — (Edema due to cardiac disease appears first 
over the dorsum of the feet and at ankles and skin over 
the lower portion of the tibia. As interference with the 
circulation becomes more marked, the dropsy ascends 
from below upward, involving the thighs, abdomen and 
finally becomes general (anasarca), when the serous 
cavities become involved. 

(Edema due to renal causes appears first in the face, 
and soon becomes general. In anaemia the dropsy first 
develops in the more dependent parts of the body, and 
in this respect resembles that of cardiac disease. 



CHAPTER IX. 

PALPATION. 

Palpation not only corroborates the data obtained by 
inspection, but also corrects it, and gives additional and 
more exact information concerning the changes in the 
praecordia and their causes. It enlarges the knowledge 
of cardiac movements by detecting pulsations too feeble 
to be noticed by the eye, and shows not only the position 
of the apex beat, but also its extent, force, character and 
rhythm. 

Y\ Tiile inspection gives ns the point at which some 
portion of the heart strikes the chest wall, by palpation 
we are able to fix the position of the anatomical apex, 
and it is thus possible to determine the true size of the 
heart. 

It is especially valuable to determine whether pulsa- 
tions are systolic, diastolic, irregular or intermittent, 
and to detect other vibratory jjheiiomena, as fremitus 
and thrills. 

In order to obtain the most satisfactory results from 
palpation, it is necessary that the patient assume an easy 
position, whether it be standing, sitting or reclining. 
When feasible, the patient should be examined in more 
than one position, as posture has a marked influence on 
the position and force of the cardiac impulse. The 
observer should place his hand lightly over the lower 
portion of the praecordia and note the general character 
of the sensation conveyed to it. Then, by the tips of the 
fingers, the exact location of the maximum apex beat 
may be determined. Frequently, when the pulsations 
are indistinct or diffuse, it is difficult to locate exactly 



234 THE CIRCULATORY SYSTEM. 

the point of maximum intensity of the apex beat. In 
such eases it is best to apply the tips of the fingers to 
the thorax beyond the point of visible pulsation, and, 
moving them along the interspaces, locate the point at 
which the elevating impulse is felt most distinctly. 

Palpation enlarges the knowledge obtained by inspec- 
tion of increase in size of the prseeordia by determining 
whether or not the enlargement is due to oedema, inflam- 
matory swelling, or new growths of the soft parts. In 
regard to the bony thorax, it determines the degree to 
which it is influenced by each cardiac heat. 

The cardiac movement is felt by the hand placed over 
the prseeordia in the region of the apex, in an adult with 
fairly thin chest walls, as a diffused throb, which at the 
fifth intercostal space ends with a distinct elevating 
impulse. The pulsation felt is synchronous with the 
visible apex beat and the carotid pulsation, and slightly 
precedes the radial pulse. In thin persons with flexible 
chest w r alls, a distinct, sharp jerk or shock may be felt 
at the base of the heart when the flat of the hand is 
applied. With the finger tips it can be localized in the 
third or fourth interspaces, close to the sternum. It is 
diastolic in time, due to the closure of the aortic and 
pulmonary valves (valve shock). In its most perfect 
manifestation, cardiac impulse is felt as a distinct 
movement or peristaltic wave passing from apex to base. 

The apex beat varies normally in its point of maxi- 
mum intensity, force and extent, as has already been 
described under "Inspection." 

Conditions Modifying the Apex Beat. — The influence of 
posture on the position of the heart is much more notice- 
able by palpation than by inspection, and must ahvays 
be taken into account. When the patient is standing, 
bending forward causes the cardiac impulse to become 
more distinct and sustained. In many cases the apex 
beat can only be located with the patient in this position, 
When in the semi-recumbent position or lying flat upon 
the back, the heart recedes from the chest wall, and the 



PALPATION. 235 

impulse becomes correspondingly weak and indistinct. 
When lying- on the left side, the heart is displaced 
toward the same side, and is felt about midway between 
its normal position and the anterior axillary line; and 
the apex impulse is not so marked, being covered to a 
greater extent by lung tissue. When lying on the right 
side, the heart is carried toward the right, and the apex 
beat is felt nearer to the sternum, or it may be under the 
sternum, and the impulse will be faint or entirely 
absent. When the heart is carried under the sternum, 
the beat may be sometimes felt as a diffused, weak epi- 
gastric impulse. 

The position of the apex beat varies with age, as has 
already been explained. During the first two years of 
life it is visible in the fourth interspace, but palpation 
shows that the true apex is near or to the left of the 
nipple line. From the second until the sixth year it 
gradually assumes a position nearer to the median line 
and lower, until after the sixth year it is found in the 
fifth interspace. In childhood the force of the beat is 
relatively greater, on account of the flexibility of the 
ribs and the condition of the lungs. In old age the 
heart is displaced downward and toward the median 
line, and the apex beat is stronger on account of senile 
hypertrophy. 

Influence of the Soit Parts. — Marked increase in the 
thickness of the thoracic wall has but a slight effect upon 
the palpable apex beat ; by firm pressure we are able to 
render the tissues in such a condition as to readily 
convey the impulse. 

Influence of the Bony Thorax. — In young subjects, with 
thin, elastic ribs, the cardiac impulse is sufficient to 
be felt as a lift or elevating sensation, not only in the 
intercostal spaces, but also over the ribs, the point of 
maximum intensity of the apex beat being much more 
distinct and less diffused than in the adult. Where the 
bony structures are rigid, the cardiac impulse influences 
the bony thorax but slightly, and the apex beat is only 



23G THE CIRCULATOR Y SYSTEM. 

felt in the intercostal spaces; in other portions of the 
thorax it is more the sensation of a jar. 

Influence of Changes in the Pleura. — Filling of the 
pleural sac with air or fluid, in addition to displacing 
the apex beat, changes the character of the impulse. 
The relation of the heart to the chest wall being changed, 
the impulse is feebler and more diffused. Occasionally 
pulsations from the heart are conveyed to the fluid in 
the pleural cavity and transmitted over the entire 
thorax. This is more likely to occur when the fluid is 
purulent (pulsating empyema). 

Contraction of the left pleura causes the heart to 
be uncovered, and a larger area to be brought in con- 
tact with the chest Avail. The apex beat is not only 
carried to the left, but it is also more visible and of a 
wider extent. When the same change occurs in the 
right pleura, the impulse may be felt to the right of the 
sternum. When the pleural surfaces are covered with 
thick, tenacious exudate, as in acute pleurisy, cardiac 
movement may cause friction fremitus to be felt with 
each beat, or only when the cardiac systole coincides 
with full inspiration or expiration. It is sometimes 
difficult to determine whether the fremitus which is felt 
is produced in the pleura or in the pericardium. If 
produced in the pleura, it does not occur if the patient 
holds his breath. The exception to this rule occurs 
when adhesions have taken place between the peri- 
cardium and the pleural surfaces. 

Influence of Changes in the Lung Tissue. — The effect of 
lung changes upon the position of the apex beat has 
already been noted. Retraction of the left lung causes 
the apex beat to become more extensive ; retraction of 
the right lung may cause displacement of the apex beat, 
with a more diffused and weaker impulse. 

General emphysema, in addition to changing the 
position of the heart and apex beat, is also apt to induce 
changes in the heart itself, causing the apex beat to 
become more feeble and diffused. In unilateral emphy- 



PALPATIO X. 237 

sema the apex beat is not only displaced by the enlarged 
lung, but, as this condition is usually associated with a 
corresponding diminution of the other lung, there is apt 

to be some change in the heart itself which modifies the 
character of the apex beat. 

Influence of Changes in the Pericardium. — Effusions 
into the pericardium cause not only elevation of the 
visible apex, but the intervention between the heart and 
the chest wall of a layer of fluid causes the beat to 
become less distinct, and at the same time somewhat 
diffused. As the effusion increases in amount, the pul- 
sation felt over the lower portion of the prsecordia is a 
peculiar, wave-like sensation, while over the site of the 
visible apex beat there is felt a weak, elevating impulse. 
In extreme effusion the only impulse noticed may be a 
diffuse sensation of fluctuation. When the pericardium 
is covered by thick, tenacious (plastic) exudate, a 
friction fremitus may be felt over the entire pr^ecordia, 
but most frequently it is limited to that portion of the 
pericardium that is not covered by lung tissue, and which 
corresponds to the area of absolute dullness on percus- 
sion. It may be detected by light pressure over the 
pnrcordia, and can be intensified by causing the patient 
to lean forward and making firm pressure in the inter- 
spaces. The fremitus occurs rhythmically with the 
cardiac action. 

Influence of Cardiac Changes. — As the palpable impulse 
is due to the impact of the heart on the chest wall, it will 
vary according to the muscular power and size of the 
heart. In the normal heart it is increased by those 
causes which produce overaction, as nervous excitement, 
pyrexia, toxic agents, exertion and irritability of the 
heart muscle, due to a beginning inflammation of the 
pericardium or endocardium. These factors will 
merely cause increase in the force of the apex beat, 
without change in its location. Hypertrophy of the 
heart modifies the character of the apex beat according 
to which portion of the organ is affected. Hypertrophy 



2 3 8 THE CIBCULA TOR Y SYSTEM. 

of the left ventricle causes the pulsation to he strong, 
prolonged and heaving or thrusting in character. The 
apex beat is well defined, and the lifting impulse, while 
marked, is not sudden. When hypertrophy and dilata- 
tion of the left ventricle are associated, not only is the 
apex beat carried downward and to the left, being fre- 
quently felt in the mid-axillary line, but the impact may 
be powerful enough to influence the entire left chest, and 
is felt as a lifting, heaving motion. 

When dilatation of the left ventricle is the most 
prominent feature, there being relative muscular weak- 
ness, although hypertrophy is present, the impulse is 
weak and abrupt, and the apex beat is ill-defined and 
diffused. The lifting sensation of the normal apex 
beat is wanting in simple dilatation of muscular weak- 
ness or degeneration. 

As normally the apex beat is due to some portion of 
the right ventricle striking the chest wall, in hyper- 
trophy of the right ventricle this area is increased and 
carried toward the median line, and the sensation felt 
by the hand is of a diffused lifting character, which is 
visibly transmitted to the epigastrium and the lower 
portion of the sternum. When dilatation and hyper- 
trophy are associated, the impulse becomes more dif- 
fused. In marked dilatation with muscular weakness, 
the impulse is of a wave-like, indistinct character, and 
may be felt to the right of the sternum. 

Palpable Vibrations, or Thrills. 

Normally, the blood passes through the cardiac orifice 
without being thrown into vibration, but when the 
smooth surfaces of these orifices are roughened or nar- 
rowed, when the valves become insufficient to close them, 
or when the blood is reduced in specific gravity, vibra- 
tions may be produced in the blood stream of sufficient 
intensity to be conveyed to the surface and to be detected 
by the hand as thrill, which has been compared to that 



PALPATION. 239 

fell over the back of a purring cat (fremissemenl cataire, 
Katzenschniirren). 

As the thrills always depend on the movement of 
blood through a cardiac orifice, it is necessary to deter- 
mine (a) their location, (b) their area of diffusion and 
(c) their relation to the period of the cardiac cycle 
(time or rhythm), as they may be systolic, diastolic or 
pre-systolic. 

Over the apex of the heart, the thrills may be due to 
mitral obstruction, mitral regurgitation, rarely to aortic 
obstruction and regurgitation. 

Thrills due to mitral obstruction are usually well 
defined and have a peculiar vibratory character, so that 
the term "purring thrill" has been given them. The 
point of maximum intensity is somewhat above and to 
the inner side of the apex. The area of diffusion is 
usually limited to that of the apex beat, although at 
times it may be carried beyond. They are felt just 
before the lifting impulse of the apex, by which they are 
usually terminated. As they occur during that portion 
of the diastole which immediately precedes the systole, 
they are said to be pre-systolic. 

Thrills felt in mitral regurgitation are usually of a 
soft, indistinct character, felt chiefly over the area of 
the maximum apex beat and occurring at the time of the 
lifting impulse. 

Thrills at the apex, due to aortic obstruction or 
regurgitation, are usually faint in character, and their 
intensity increases as the hand passes upward over the 
prsecordia toward the base of the heart. 

Thrills felt over the upper portion of the chest may 
be produced at the aortic or the pulmonic orifices. While 
pulmonic obstruction and regurgitation may be attended 
with vibrations sufficiently powerful to be felt at the 
surface as thrills, they are so extremely rare that they 
may practically be left out of consideration. 

Thrills produced by aortic obstruction have their 
point of maximum intensity at the second intercostal 



240 THE CIRCA rLA TOE V SYSTEM. 

cartilage an the right side. They arc transmitted 
upward, and occur synchronously with the apex beat 
and the carotid pulsation. The character of the thrill 
has nothing distinctive. 

Thrills occurring with aortic regurgitation have the 
point of maximum intensity at the second right costal 
cartilage or slightly below, and may be transmitted to 
the sternum or be felt over the entire precordial area. 

Palpation of the Blood- Vessels. — The heart, in connec- 
tion with the arterial and venous systems, constitutes the 
circulatory apparatus, and palpation of the heart would 
be incomplete and misleading for diagnosis if both 
arterial and venous systems were not included. 

Palpation of the Aorta. — Normally, the aorta is 
beyond the reach of the examining finger, except in a 
few cases where deep pressure behind the sternum in 
the episternal notch detects a faint pulsation. In 
enlargement of the calibre of the aorta, as occurs in 
diffuse dilatation of the blood-vessel, secondary to 
valvular disease of the heart, or dependent upon 
atheroma, or in aneurism, the aorta may be palpable 
not only above the clavicle and sternum, but also in the 
first and second intercostal spaces on either side of the 
sternum. 

In dilatation of the transverse portion of the aorta, 
the pulsation of the blood-vessel may be transmitted to 
the upper portion of the sternum, and may be also 
accompanied by a thrill which is synchronous with the 
heart action. 

Aneurism of the ascending and transverse portions of 
the aorta may communicate pulsations to the trachea 
and larynx, giving the tracheal tug. In order to obtain 
this sign, the patient is placed in the erect position, 
standing or sitting, the mouth closed and the chin ele- 
vated to its fullest extent. The examiner grasps the 
cricoid cartilage between the thumb and finger, and 
makes gentle upward pressure. 

On account of the tendency of the innominate and 



PALPATION. 241 

carotid arteries to transmit a pulsation to the trachea, 
Evart lias advised that the examination be made in the 
following manner: "The observer stands behind the 
seated patient, whose head is thrown back and supported 
against the observer's chest. The tips of both index 
fingers are then inserted under the lower edge of the 
cricoid cartilage, which is gently raised by them/' when 
a very distinct and unmistakable traction downward is 
felt with each systole of the heart. In extreme aortic 
regurgitation slight pulsation may be felt in the trachea, 
but it lacks the peculiar dragging, tugging sensation. 

Tracheal tugging is only present when "the aneurism 
is so situated that it presses from above downward upon 
the bronchi near their bifurcation, or upon that portion 
of the trachea just above it." As an aneurism, to give 
such a pressure, must be given off from the posterior and 
inferior portions of the transverse division of the aorta, 
tracheal tugging is an early manifestation. 

THE PULSE. 

When an artery is palpated to obtain the pulse, a 
portion is usually selected where the vessel can be com- 
pressed between the examining finger and a firm point, 
as a bony eminence. The temporal, facial or radial 
arteries may be selected as meeting this requirement. 
On account of the readiness of access, and also from the 
fact that its condition is not readily disturbed by dis- 
ease of the structures which it supplies, the radial vessel 
is preferred. 

In order to readily appreciate all the elements of the 
pulse, it is necessary that a certain amount of the vessel 
be under observation. This is attained by the classical 
method of placing the tips of three fingers on the radial 
artery, the most sensitive and most highly educated 
index finger nearest the heart, while the thumb supports 
the wrist at the back. Another is "that the patient's 
hand and forearm is supported by the examiner's left 
1G 



242 THE CIB( 7 LA TOR Y 8 TSTEM. 

hand, while the fore finger of the righl hand is applied 
longitudinally over the artery. In this way the vessel is 
felt over a considerable length of its course by one finger 
of the observer, and varying degrees of pressure can be 
applied to it, while the skin can be pushed up and the 
size of the artery and the character of the arterial coats 
can be determined." (Sanson.) 

The sensation that is felt when an artery is palpated 
is due to the momentary increase in arterial pressure 
that occurs when the left ventricle empties itself into the 
aorta. The pulse wave distends the vessel that has been 
partially empty during diastole, and whose lumen is 
still further narrowed by the examining finger. "The 
pulse then indicates simply the degree of duration of the 
increased pressure in the arterial system caused by the 
ventricular systole." (Broadbent.) 

It is necessary to bear in mind that three factors are 
concerned in the production of the pulse: (1) Cardiac 
action, which determines (a) frequency (fast or slow), 
(b) force (strong or w r eak), (c) rhythm (regular, 
irregular or intermittent). 

(2) The elasticity of the blood-vessel, upon which 
depends the degree of compressibility of the pulse (hard 
or firm, compressible or incompressible). 

(3) Resistance in the arterioles and capillaries, which 
determines the readiness with which the larger blood- 
vessels are emptied during the period of diastole and 
regulates (a) the size of the pulse ; whether the excur- 
sion of the artery compressed by the finger is wide or 
narrow, when the pulse is spoken of as large or small ; 
( b) the duration of the time that the wave is perceptible 
to the touch, so that the pulse is long or short ; (c) ten- 
sion or the degree of distension of the blood-vessels 
present throughout the cardiac diastole, and especially 
near its end. 

Size, duration and tension are usually associated in 
a definite manner. Low resistance in the artery and 
capillaries give the pulse of large size, short duration and 



PA LP iTION. 213 

low tension, while great interference causes the pulse to 
be small, long and of high tension. 

These three factors are more or loss correlated and 
react on each other, and each exerts its own peculiar 
influence on the pulse, both in health and disease. 

The Normal Pulse. — The normal pulse for the healthy 
adult male heats 72 times per minute (frequency) ; the 
strength of each distending' impulse is the same (force), 
and the heats follow each other at regular intervals 
(rhythm). The lumen of the artery is readily obliter- 
ated by the examining finger nearest the heart, and the 
pulse wave is stopped at the point of pressure, beyond 
which, distally, the artery cannot be detected as a sepa- 
rate structure. The pulse wave is felt as a dilating force 

Fig. 29. 




/a 

Sphygmographic tracing of normal pulse. 

a, b, percussion up-stroke; a, b, c, percussion wave; c, <l, e, tidal wave; e,f, g, 

dicrotic wave ; d, e, f, aortic notch ; /, g, diastolic period. 

of some volume (size), which does not raise the finger 
to the full height at once, but takes a definite time to 
reach its acme and declines in the same manner (dura- 
tion) ; and between the pulsations the artery is felt 
under the finger, and can be compressed with greater or 
less ease according to its degree of distension (tension). 
It is necessary to distinguish between the incompressi- 
bility of a blood-vessel due to condition of its walls and 
the amount of pressure necessary to overcome the dis- 
tension of the vessel due to the blood pressure (tension). 
When the pulsations in the artery are obliterated with 
difficulty, if the incompressibility is due to increased 
thickness of the arterial coats, the artery will be felt 
beyond the point of compression as a more or less rigid 



214 THE ( IBCl LA TOM Y SYSTEM. 

cord ; while if the incompressibility is due to high 
arterial tension, it will be impossible to detect tlie artery 
beyond the compressing finger. 

While the above are the average characteristics, each 
pulse may present individual peculiarities in the three 
factors spoken of. Both radial' arteries should be 
examined, and when differences are detected it is neces- 
sary to determine whether they are due to anomaly in 
the size or distribution of the arteries, or are dependent 
upon pathological changes, as aneurysms, plugging of 
the blood-vessel, etc. 

I. Conditions Modifying the Cardiac Elements of the Pulse. 

(a) Frequency. — While the average pulse rate is 72 
per minute, there are certain normal variations. 
Usually the pulse of females is slightly quicker — 80 per 
minute — and it has been claimed that in tall people the 
pulse is slower. At birth the pulse is 120 to 140, and 
gradually diminishes in frequency until at six years of 
age it is 100, and at puberty 80 or less. In old age the 
pulse becomes slower, but in extreme age its frequency 
is increased. There is also a diurnal variation in the 
pulse rate, corresponding to the body temperature, it 
being more frequent in the afternoon and evening and 
after eating, slower during sleep and during the early 
morning hours. While a pulse of 60 may be normal 
for one adult and 100 for another, usually a pulse 
of over 90 per minute is morbid. 

Increase in Frequency. — The rate of the pulse may 
be increased by the following: (a) Muscular exertion. 

(b) Mental and emotional excitement; the degree of 
increase will vary with the individual, according to the 
irritability of the nervous system (temperament). 

(c) Reflex irritation from other organs, especially the 
abdominal and pelvic viscera, (d) Diseases of the 
nervous system, especially those involving the nervous 
mechanism of the heart through the pneumogastric, 
sympathetic nerves or the cardiac ganglia, (e) Fever. 
As a rule, for each degree of temperature above the 



PALPATION. 

Sphygmographic Tracings of the Pulse. 
Fig. 30. 



245 




Right radial artery. Left radial artery. 

Aneurysm of arch of aorta. 



Fig. 31. 

Slow pulse (60) (acromegalia). 

Fig. 32. 

Small, thready, rapid pulse (98) (chill of malaria fever). 

Fig. 33. 

High-tension pulse (chronic nephritis). 

Fig. 34. 





Low-tension dicrotic pulse (pneumonia, eight hours before death). 

Fig. 35. 



Low-tension pulse, feeble cordiac action (typhoid fever, third week). 



24G 



THE CIRCULATORY SYSTEM. 



normal there is an increase of eight or ten beats. Cer- 
tain diseases do not conform to this rule ; thus in typhoid 
fever the pulse is generally slow in proportion to the 
temperature, and is of diagnostic value in differentiat- 
ing this disease from tuberculosis and septic conditions. 
When, in typhoid fever, the pulse rate corresponds 

Fig. 36. 




Rapid (100) low- tension, dicrotic, on admission. 



Fig. 37. 




Twelve hours later (80), free stimulation, slower (88). 



Fig. 38. 




Six hours after crisis (86). Four days later, no stimulation. 
Pneumonia, showing- variation in pulse. 



to the temperature range, it indicates a grave con- 
dition. In scarlet fever, with the very beginning of 
the throat symptoms, the pulse ranges from 120 to 
160, and this is of great aid in differentiating scarla- 
tinal sore throat from that due to other causes, as 
diphtheria, simple follicular tonsillitis, etc. In fevers 



PALPATION. 217 

due to septic infection, the pulse is accelerated out of 
proportion to the range of temperature, and in the 
puerperium a rapid pulse, with slight elevation of 
temperature, is a suspicious sign, (f) Anaemia and 
debility, (g) Respiratory diseases. In nearly all of 
the acute inflammatory diseases of the respiratory tract 
the pulse rate is increased. Normally, the ratio 
between pulse and respiration is 4 : 1. This ratio is 
disturbed in respiratory diseases, such as pneumonia, 
when the ratio becomes 3 : 1, or even 2 : 1 ; or equal. In 
febrile conditions due to pulmonary disease, this sign is 
found of value when the usual physical signs are absent. 
( li ) Cardiac conditions. The pulse may be accelerated 
in all valvular diseases, although as long as compensa- 
tion is perfect the increase may be very slight. When 
there is muscular insufficiency, the rate is markedly 
increased, especially upon exertion. 

Acceleration of the pulse is a prominent symptom 
of neuroses of the heart. In Grave's disease the pulse 
ranges from 100 to 120; in paroxysmal tachycardia it 
may reach 160 or 200, but does not remain permanently 
at this point, although it may be constantly above the 
normal. In irritable heart (paroxysmal hurry) it is 
also increased. 

Rheumatoid arthritis, before marked deformity of 
the joints, frequently has a pulse, as an early symptom, 
of 110 or 120. 

The rate of the pulse bears a definite relation to the 
amount of tension in the blood-vessels, and should 
always be considered in this relation. 

Diminution in Frequency. — As mentioned before, the 
pulse may be habitually slow as an individual pecu- 
liarity. Usually a pulse under 60 is considered morbid, 
while a pulse of 40 is usually of grave significance. 

The pulse may be slowed by (a) reflex nervous irrita- 
tion, (b) Nervous diseases, especially those which 
cause increase in the intercranial pressure, as tumors, 
hemorrhage and meningeal effusion. It is also slowed 



248 THE CIRCULATORY SYSTEM. 

in certain cases of mania, melancholia and general 
paralysis of the insane, and in injury to the cervical 
portion of the spinal cord. A slow pulse in epilepsy is 
always a grave symptom. In myxcedema the pulse is 
constantly slow, (c) Convalescence from fevers, (d ) 
Toxaemias, especially bile, urea and certain acute dis- 
eases, (e) Increase in arterial tension, (f) Cardiac 
disease. A slow pulse is a grave symptom when it 
occurs in cardiac disease, and was formerly supposed to 
be pathognomonic of fatty degeneration of the heart, 
but is not usually present except when the degenerative 
change is due to atheroma of the coronary arteries. 

The pulse is not always a true guide to the frequency 
of the heart, as a form of slow pulse occurs in which 
only every other beat of the heart is felt at the wrist. 
The examination of the heart shows that the beat which 
is not felt as a pulse in the artery is feeble and incom- 
plete. This type of slow pulse is most frequently 
present in mitral stenosis. This form of infreqneney 
often alternates with a form of irregularity called 
"pulsus bigeminus," as will be explained later. 

(b) Fobce. — The force of the pulse wave is 
dependent on the energy with which the blood is forced 
by the ventricle into the aorta. It bears a certain rela- 
tion to the force of the apex beat, so far as it (the apex 
beat) depends upon the muscular strength of the left 
ventricle. This rule holds good as long as the ventricle 
propels into the aorta the normal amount of blood in 
the normal time, as the fullness of the arterial system 
during the entire cardiac cycle is an important element 
in the strength of the pulse. 

Increase in Force. — The force of the pulse wave is 
increased (a) when the cardiac action is more vigorous 
than normal, as occurs in exercise, in mental and 
emotional excitement, and in cardiac neuroses, as 
Grave's disease. (b) When the cardiac muscular power 
is increased above the normal, due to change in the 
muscle, as occurs in simple hypertrophy of the left ven- 



PALPATION, 249 

tricle. When, in addition to hypertrophy of the muscle 
wall, the cavity of the left ventricle is enlarged (dilata- 
tion), not only is the force of the blood wave augmented, 
but it has greater volume. 

Diminution of Force. — The pulse wave may be de- 
creased in strength (a) when the contraction of the 
cardiac muscle is less forcible on account of general 
muscular weakness, as in debility, or due to lack of 
nerve tension, as in neurasthenia, etc. (b) When there 
is true muscular weakness, as occurs in cardiac degenera- 
tion, which may be primary or secondary to valvular 
disease of the heart, (c) When the amount of blood 
that is forced into the aorta is decreased through imper- 
fect emptying of the heart from cardiac weakness, from 
imperfect filling of the left ventricle, and general reduc- 
tion in the amount of blood, as in hemorrhage. 

Irregularity in Force. — In health the individual beats 
have the same volume. Under certain conditions there 
is inequality of force, some of the beats being fuller than 
others. This form of irregularity is present most fre- 
quently in mitral regurgitation, when dilatation and 
weakness of the left ventricle occur; it may be made 
more pronounced by raising the arms above the head, 
increasing the action of gravity. Its presence should 
always direct attention to the condition of the cardiac 
muscle. When irregularity in force is due to muscular 
insufficiency, slight exertion is often sufficient to induce 
also irregularity in rhythm. 

(c) Rhythm. — The normal rhythm of the heart may 
be disturbed in two ways: (a) A beat is dropped at 
more or less regular intervals, giving the intermittent 
type of pulse, (b) The beat occurs at irregular inter- 
vals, giving the true irregular or arrhythmical pulse. 

Intermittent Pulse. — Intermittent pulse has the char- 
acteristic that, with the exception of the missing beat, 
the pulse is regular. The intermission may occur 
according to rule ; that is, after a definite number of 
beats, as when the fifth, seventh, eleventh or twenty-first 



250 THE CIBCULA TORY SYSTEM. 

beat is lost; or it may follow no rule. Examination of 
the heart may show a corresponding omission of the 
cardiac systole (pulsus defieiens), or that there is a 
cardiac systole, but too weak to be felt at the radial 
artery (pulse intermittens). 

When the intermittent pulse is habitual, the inter- 
mission is apt to be according to rule. This form is of 
little clinical significance, being often a constitutional 
peculiarity ; or it may be caused by the use of tea, coffee, 
tobacco, etc. It must be borne in mind that the inter- 
mission usually disappears during pyrexia from any 
cause, and returns with the normal temperature. When 
it returns during the height of the temperature, it is an 
unfavorable sign. 

In degeneration of the myocardium and in valvular 
diseases the pulse may be intermittent while the patient 
is at rest, but on exertion the intermission is replaced by 
true irregularity, with shortness of breath and other 
signs of cardiac insufficiency. When the intermission 
is due to some disturbance of innervation, on exertion 
such change does not occur, or the rhythm may become 
perfectly regular. Broadbent claims that an intermit- 
tent pulse is not a contraindication to the administration 
of anesthetics (chloroform), but that the condition of 
the pulse should be watched during the early stage of 
narcosis. Generally the intermission disappears, but if 
from the first the pulse becomes weak and irregular, the 
administration of the ana?sthetic should cease. The 
same rule applies to ether and nitrous oxide. 

Irregular Pulse. — Irregular pulse has the character- 
istic that the beats follow each other at irregular 
intervals, and are also irregular in force. The tend- 
ency to irregularity varies at different periods of life. 
During infancy the pulse is easily disturbed in all its 
cardiac elements, especially its rhythm. The same 
tendency to arrhythmia is noted in extreme old age. 
Irregularity of the pulse may be a normal condition in 
individuals when it is constant. 



PALPATION. 



251 



The causes of irregularity may be: (a) Reflex irri- 
tation from abdominal or pelvic viscera, especially when 
they arc associated with flatulency and displacement 



Fig. 39. 




Pulse irregular in rhythm and force (myocarditis with dilatation). 

Fig. 40. 




Mitral regurgitation. 

Fig. 41. 

Aortic obstruction. 

Fig. 42. 




Aortic regurgitation. 



Fig. 43. 



Mitral stenosis. 



upward of the diaphragm, 
nervous system by shock 
neurasthenia, anaemia, debility, etc 



(b) Disturbances of the 
grief, continued worry, 



(c) Diseases of 



2 5 2 THE CIBCULA TOE Y 81 r 8 TEM. 

the brain and meninges, (d) Toxaemia, due to alcohol, 
tea, coffee, tobacco, digitalis, belladonna, etc., or that of 
the infectious diseases, especially the early stages. The 
irregularity that occurs later in acute disease may be 
due to the toxaemia or to degenerative changes in the 
cardiac muscle, (e) Cardiac diseases. In valvular 
disease marked irregularity does not occur during stage 
of compensation, but is one of the early signs of muscu- 
lar insufficiency. In mitral stenosis it is a common, but 
not grave, symptom. In all forms of myocarditis it is 
an important prognostic sign. 

II. Conditions Modifying the Elasticity of the Arteries. 
— The sensation conveyed to the finger by the normal 
artery has been described, and attention called to the 
necessity of discriminating between the degree of com- 
pressibility due to changes in the coat of the artery and 
that due to increased blood pressure. When the coats of 
the arteries are thickened and rendered inelastic by 
increase of fibrous tissue, the pulse wave will be obliter- 
ated with difficulty, and beyond the point of compression 
distally the artery will be easily detected as a more or 
less rigid cord. As the tube becomes more inelastic, it 
becomes longer and tortuous, and each pulse wave is felt, 
not as a beat, but as a worm-like movement. Calcare- 
ous deposits may be detected as isolated plates, and 
"may feel like a string of beads under the finger." 

III. Conditions Modifying Resistance in Arteries and 
Capillaries. — The amount of arterial and capillary resist- 
ance determines the size, intensity and duration of the 
normal pulse, and any change in the degree of resistance 
influences all of these elements. 

Diminution of Resistance. — When the resistance 
is reduced below normal, there is a relatively greater 
increase in the distension of the artery with each ven- 
tricular systole. The pulse wave passes more rapidly 
under the finger, and between the beats the artery is but 
slightly distended with blood, and is almost obliterated 
by light pressure of the examining finger ; and the pulse 



PALPATION. 

fell al ilu 1 wrist has the fo 
pulse wave dilates suddenly the flattened artery, giving 
the sensation of a large-sized pulses it does not gradually 
reach its acme, but seems to reach the finger full size. 
The beat is sharp, passes quickly under the finger (short 
duration) and the artery remains distended but for a 
very short time (tension rapidly falls). This type of 
pulse is spoken of as "large, short, low-tension pulse." 

In the normal pulse the examining finger can scarcely 
detect dicrotisnij which is caused by the elastic recoil of 
the artery on the closure of the aortic valves, although it 
is very perceptible in the sphygmograph tracing. (Fig. 
29.) " 

When the resistance in the arteries is very low, this 
wave becomes quite apparent to the finger, and the pulse 
is spoken of as dicrotic. In Ioav tension the force and 
frequency of the heart determines the type of pulse. 
When the heart is beating rapidly and forcibly, the 
arteries are kept well filled, the pulse wave is felt 
as a large, sharp, well-sustained beat, and the pulse is 
called "full and bounding," and is easily obliterated. 
Dicrotism, while present, is not noticed, on account of 
the size of the primary pulse wave. As the force of the 
heart diminishes, the pulse becomes less full, and is 
sharper and shorter and more easily obliterated by light 
pressure on the artery, and the dicrotic wave becomes 
more pronounced. This type of pulse is spoken of as 
the "gaseous pulse." When the heart power becomes 
insufficient to empty the left ventricle, the pulse is 
weak and characterless — "small, running pulse" (page 
245). 

Causes of Low Tension. — (a) Low tension may be 
a constitutional peculiarity in some individuals and 
families, when it may be associated with increased fre- 
quency in some cases and obesity and weak cardiac action 
in others (diminution in capillary resistance). (b) 
Temporary low tension is caused by warmth, as weather, 
baths, hot drink and food, (c) It may be dependent 



254 THE CIRCULATORY SYSTEM. 

upon nervous causes, as mental or nervous exhaustion 
from whatever cause, (d) Debility due to malnutri- 
tion or secondary to chronic disease. (e) Pyrexia 
generally causes a full, bounding pulse, usually in 
proportion to its degree. Later the pulse may become 
weak, quick and dicrotic, on account of the effect 
of the high temperature on the cardiac muscle or the 
influence of the toxines on the heart itself, or on the 
nervous system. (f) Cardiac diseases. As the press- 
ure in the arterial system depends upon the amount of 
blood that is forced into it, as well as the resistance to 
the passage of the blood through the arterioles and 
capillaries, the tension will be lowered whenever the 
heart is unable to empty itself, due to valvular disease 
or to muscular weakness. In aortic insufficiency the 
collapsing or water-hammer pulse is due to the sud- 
den fall in the blood pressure caused by the free regurgi- 
tation of blood into the ventricle. The peculiarities of 
this pulse will be described under aortic regurgitation. 
Increase of Resistance. — In normal conditions there 
is a certain correlation between the force and frequency 
of the heart and the outflow from the arterioles, and a 
normal mean blood pressure is maintained. The normal 
blood pressure varies at different periods of the cardiac 
cycle. With cardiac systole, the pressure is raised to 
the maximum, and the artery is felt as a tense, distended 
tube. During diastole, as the pressure gradually sub- 
sides, the tube becomes lax, and can no longer be felt. 
When resistance to the outflow of blood is increased, the 
tension is increased, the pressure in the blood-vessels 
does not subside ; and the artery remains filled, so that it 
is detected not only with the beat, but in the interval. 
The sensation conveyed to the finger by the pulse wave 
also is changed. The examining finger not causing so 
marked a flattening of the artery, there is less motion 
felt, and the pulse wave slowly reaches its height to 
slowly decline. As the size of the artery is not much 
altered between the pulse w r aves by light pressure, the 



PALPATION. 255 

pulse is sum 11, and the wave 1 gradually distends the ves- 
sel and is fell for a relatively long period, and the artery 
remaining perceptible in the interval. 

As in low {elision, so in increased resistance the type 
of the pulse will vary with the force and frequency of 
the heart and the condition of the large blood-vessels. 
When the muscular power of the heart is sufficient to 
overcome the resistance in the blood-vessels, and the 
muscular coats of the aorta oppose the increased cardiac 
action, the tension in the arteries will be sustained 
almost uniformly during* the interval, and the pulse will 
be correspondingly small, long and of high tension. 

When the heart fails, the pulse becomes irregular and 
arterial pressure is lowered. When, on the other hand, 
the aorta and large vessels yield to the blood pressure 
and become dilated, the pulse becomes larger and the 
duration is shorter, although the arteries remain over- 
filled during diastole. 

Causes of High Tension, — (a) Temporary high-ten- 
sion pulse may be caused by increase in the amount of 
blood, as occurs for a short time after meals or after tak- 
ing large quantities of water, and is persistent when the 
elimination of the fluid by the skin and kidneys is inter- 
fered with, producing permanent overdistension of the 
blood-vessels, (b) It may be also temporarily increased 
by frequent and powerful overaction of the heart, as 
occurs in mental or emotional excitement and in the 
early stage of physical exertion. Or (c) it may be due 
to temporary increased resistance in the blood-vessels, as 
occurs from external cold, congestive chill, or hysteria. 

Permanent high tension may be caused by all those 
factors which cause increased resistance in the capil- 
laries, (a) as drugs, ergot and the digitalis group; (b) 
toxaemia, as occurs in gout, rheumatism, lead poisoning 
and in renal disease; (c) changes in the walls of the 
capillaries which interfere with permeability, as 
atheroma and arterio-capillary fibrosis. These changes 
may be primary or secondary. 



CHAP TEE X. 

PERCUSSION. 

By percussion of the cardiac region it is possible 
(a) to determine the size of the heart in certain dimen- 
sions only; (b) its relation to other thoracic and 
abdominal organs; (c) changes in the outline of certain 
portions. 

Percussion of the praecordia gives two areas: (1) 
The area in which the clear pulmonary resonance 
becomes more and more impaired by the presence 
of the airless structure of the heart ; that is, the area of 
relative cardiac dullness. (2) The area in which no 
pulmonary resonance can be detected, the area of abso- 
lute cardiac dullness or cardiac flatness. The percus- 
sion outline of these two areas is most difficult to 
determine. Many claim that they have no value, or, at 
least, only a limited value in the diagnosis of cardiac 
diseases. 

The amount of information obtained by percussion 
over the prsecordia depends upon the technique and the 
acuteness of the examiner, and whether or not the 
examination is conducted methodically and for a definite 
purpose. 

Methods of Examination. — In percussing for relative 
dullness, it is most important that the -line should be 
determined at which the normal pulmonary resonance 
is impaired by the underlying heart. 

Percussion is begun over the thorax at some distance 
from the anatomical borders of the heart. The finger is 
placed across the ribs parallel with the sternum, and 
forcible percussion is made, the finger being moved 



PERCUSSION. 25? 

inward toward the cardiac area till slight change in 
the percussion note is detected. This point is marked 
on the thorax, and the same area is again percussed with 
blows varying in strength, with the finger both in the 
vertical position and also parallel to the ribs lying in the 
interspaces, until the positive point of cardiac dullness 
is determined. This method is carried on at different 
levels, until the outermost area of cardiac dullness is 
outlined. 

After this has been determined, the examiner then 
proceeds to outline the point at which the pulmonary 
resonance ceases and the heart, in contact with the chest 
wall, causes a perfectly flat note. It is necessary that 
the percussion blows vary in force as we proceed from 
the outer line of cardiac dullness, where the layer of 
lung is relatively thick, toward that of cardiac flatness. 

The Area of Cardiac Dullness. — In the normal adult the 
outer area at which cardiac dullness is detected is as 
follows : On the right side no change is noted above the 
third rib, except occasionally a slight loss of resonance 
due to the underlying aorta. Although the right auricle 
projects beyond the sternum opposite the third costal 
articulation, it is impossible to accurately map out the 
border which extends beyond the sternum, as the thick- 
ness of the pulmonary tissue is so great that percussion, 
sufficiently strong to penetrate to the underlying heart, 
will set up lateral vibrations also, which, being conveyed 
to the sternum, give a resonant note. The most that 
can be detected on the right side by skillful percussion 
and a trained ear is a slight change in resonance, extend- 
ing from the fourth rib to the area of liver dullness. 

On the left side, that portion of the heart that lies 
above the third rib cannot be detected by percussion, on 
account of the thickness of the pulmonary tissue and its 
close proximity to the sternum. At the lower level of 
the third rib, close to the sternum, the deep cardiac 
dullness is detected. The line of dullness extends in 
a curved line across the third intercostal space to 
17 



258 THE CIRCVLA fOR V 8 YSTEM. 

the middle of the fourth rib, o 1 /^ to 4 inches from 
the mid-sternum and just inside the nipple line. From 
this point it runs almost vertically downward to the 
sixth rib, just inside the nipple line. When the heart 
and structures contained within the mediastinum are 
normal, they do not influence to any appreciable degree 
the resonance of the sternum. (Fig. 22.) 

The Area of Cardiac Flatness. — That portion of the 
heart that lies in direct contact with the chest walls gives 
a perfectly flat sound on percussion, and corresponds 
in outline to the anterior margin of the left lung. The 
resonance of the sternum prevents that portion of the 
heart that lies between the anterior edge of the right 
lung and the left edge of the sternum being detected by 
percussion. The thin lingula pulmohalis that covers 
the apex of the lung does not modify the flat percussion 
note. (Fig. 21.) 

The normal area of cardiac flatness is somewhat 
quadrangular in shape. The right border extends along 
the left edge of the sternum, from the upper edge of 
the fourth rib and along the border of the sixth rib, 
where it merges into the hepatic flatness. 

The upper borders run diagonally across the fourth 
rib for about two inches, and then vertically downward 
to the sixth rib. Accurate mapping out of the borders 
of cardiac dullness and flatness being very difficult, some 
authors have recommended that the area of cardiac flat- 
ness be estimated in two directions only. 

(1) The vertical line. Percussion is made along the 
para-sternal line, one inch to the left of the sternum, 
and the following varieties of resonance are noted on 
percussion over the normal heart: (a) From the 
clavicle to the upper border of the third rib full pul- 
monary resonance is detected, (b) From the third rib 
there is a gradual diminution of resonance and a height- 
ening of pitch (cardiac dullness), until at the upper 
border of the fourth rib there is absolute loss of reso- 
nance (cardiac flatness), (c) From the upper border 



PERCUSSION. 250 

of the fourth rib the sound is flat, and merges, below the 
sixth rib, into that of the liver. Over this norma] flat 
area very forcible percussion may detect a deep-seated, 
tympanitic resonance when distension of the stomach or 
intestines is present. 

(2) Transverse line. Percussion is made along a 
line which corresponds to the upper edge of the fourth 
rib on the left side. The sound is flat for 2 to 2 1 / /> 
inches from the edge of the sternum, when it merges 
gradually into dullness, which terminates just inside the 
nipple line. 

Numerous modifications of the ordinary method of 
percussion by the finger have been devised in order to 
increase the ability to outline the heart. The most 
important are: (a) Auscultatory percussion (page 
04) and (b) plessimetric percussion or Sanson's method. 
Instead of the finger, a pleximeter of vulcanite is used. 
This pleximeter consists of two thin, flat, oblong plates, 
one 1 x l/o inch, the other % x % inch, joined in the 
middle by a central square column l 1 /^ inches high. It 
is closely held to the chest wall by the index and middle 
fingers of the left hand, placed on either side of the 
vertical column. "The observer commences by apply- 
ing the pleximeter with its long diameter parallel to the 
sternum, about midway between the axilla and the right 
sternal border, percussion being made upon the summit 
of the column by one or two fingers of the right hand, 
the strokes from the wrist being sharp and decisive, 
though not necessarily forcible. This procedure in the 
normal conditions elicits the normal thoracic vibrations. 
The pleximeter is then approached nearer and nearer — 
always in parallel lines — to the sternum, until the line 
is reached where the vibrations are sensibly modified. 
By slightly inclining the pleximeter so that the vibra- 
tions come from its left edge, there is practically a line 
of surface without noticeable breadth. The point at 
which the resonance is modified is marked. By repeat- 
ing the process just described at higher and lower levels 



2 00 THE C1BCULA TOR Y SYSTEM. 

and uniting the marks, the observer delineates the area 
on the right side of the outer border of the heart dull- 
ness. In like manner, by percussing from above down- 
ward, with the long diameter horizontal instead of 
vertical, the upper limit of the liver, as indicated by an 
area of modified vibrations, is arrived at." 

In percussing on the left side of the chest, the observer 
begins at the left of the second rib, 2 or 3 inches to the 
left of the sternal border, and approaches to the right 
until the line of modified vibration is arrived at, which 
will be nearly parallel with that obtained on the right 
side. 

Percussion is made at different levels, as on the right 
side, until the heart is outlined. 

By this method not only is the outer border of the 
heart noted by the ear, but also detected by difference 
in vibrations, as felt by the finger resting on the lower 
plate. A certain amount of experience is needed in 
order to obtain the best results by this method. 

Conditions Modifying the Normal Areas of Cardiac Flat- 
ness and Dullness. — Both areas may be proportionately 
increased or diminished, or the dimensions of one may 
be altered at the expense of the other. 

Normal Variations. — The size and location of the 
percussion areas are influenced (a) by the age of the 
individual; (b) by the posture of the patient; (c) by 
the condition of the lungs according to forcible inspira- 
tion and expiration; (d) by the position of the heart 
due to elevation or depression of the diaphragm. 

In children the heart is relatively larger than in 
adults, and lies higher in the thorax, while the greater 
elasticity of the lungs and flexibility of the bony thorax 
causes a much larger portion of the heart to be un- 
covered by lung tissue and in closer contact with the 
chest wall. In children, during full inspiration, the 
area of cardiac dullness is relatively increased, while 
that of flatness is diminished ; and the reverse condition 
obtains during shallow breathing and full expiration. 



PEBCUSSION. 261. 

The clast icily of the sternum and costal cartilages per- 
mits dullness to be detected at the right border of the 
sternum. The upper border of cardiac dullness reaches 
the middle of the second intercostal space in the para- 
sternal line, and the outer left border to the nipple line 
at the third interspace. At the lower border of the 
fourth rib it extends a quarter to a half inch beyond the 
nipple line. The shape of the area of cardiac dullness 
is somewhat semicircular, with the convexity upward. 
The area of absolute flatness in children is also increased, 
in extent and raised by the width of an interspace. The 
right border is close to the left sternal margin; the 
upper line is in the third interspace, and extends almost 
straight across to the upper border of the third rib, close 
to the mammary line. The left border is usually just 
within this line, and extends to the lower edge of the 
fifth rib. 

It is necessary to bear in mind the variations in the 
cardiac percussion area that occur in children, as they 
have an important bearing on the diagnosis of effusions 
into the pericardium. 

In old age the areas are smaller and lower in position. 
In the left para-sternal line, the upper limit of dullness 
is about the lower border of the fourth rib, and of flat- 
ness about the middle of the fifth rib. The left border 
is also nearer the median line. 

The position of the patient alters in a slight degree 
the percussion areas. They are the same whether the 
patient is lying on the back or in the upright position. 
When lying on the right side, the area of flatness to the 
left of the sternum diminishes or disappears entirely. 
A smaller area of flatness may be detected just to the 
right edge of the sternum, in the third interspace. 
AYhen lying on the left side, the area of flatness is 
increased, the left border being carried nearly to the 
mammary line. 

Influence of the Soft Parts. — The effect of the soft parts 
on the resonance from the thorax has already been con- 



2G2 THE CIRCULATORY SYSTEM. 

sidered. When the thorax is thickly covered, it is 
impossible to accurately outline the area of cardiac flat- 
ness, that obtained by light percussion being generally 
carried too far to the left. 

Influence of the Bony Thorax. — The elasticity of the 
bony thorax also exerts an influence on the percussion 
areas. As before explained, the highly elastic thorax 
of the child will give a much more accurate outline of 
the heart than the rigid and more resonant thorax of the 
adult. 

Influence of the Lung and Pleura. — As the area of 
cardiac flatness corresponds to that portion of the heart 
that is uncovered by lung tissues and the area of rela- 
tive dullness to the part covered by a thin layer, 
both areas will be increased or diminished by changes 
occurring in the lung or pleura. The normal varia- 
tions in size occur, as has already been mentioned, 
during the ordinary acts of respiration. Enlargement 
of the lung, as occurs in general emphysema, causes a 
smaller part of the heart to be in contact with the chest 
wall, increases the thickness of the layer of lung cover- 
ing the heart, and displaces the heart downward 
and toward the median line. These changes cause the 
area of cardiac flatness to be diminished or absent. As 
emphysema is usually attended with hypertrophy and 
dilatation of the right side of the heart, the areas of 
percussion dullness and flatness do not correspond to the 
size of the heart, so that a normal area of cardiac flat- 
ness, occurring with other physical signs of emphysema, 
is always indicative of a marked right-sided cardiac 
hypertrophy and dilatation. In compensatory emphy- 
sema of the left lung, both cardiac dullness and flatness 
to the left of the sternum may be diminished or absent. 
AVhen the heart is displaced to the right, an area of 
varying dullness may be detected to the right of the 
sternum. In compensatory emphysema of the right 
side, pulmonary resonance extends to the left of the 
sternum, and the right border of cardiac flatness is 
moved further from the left sternal margin. 



PERCUSSIOM 2b J 

The area of cardiac flatness may be enlarged in 
all directions by retraction or consolidation of the 
anterior border of the lung, or thickening of the pleura. 
Retraction of the anterior border of the left lung, by 
uncovering the heart, increases the area of flatness at 
the expense of that of dullness, the shape of the area of 
flatness corresponding to changes in the lung and 
secondary displacement of the heart. 

When the anterior border of the right lung is 
retracted, cardiac dullness may be detected to the right 
of the sternum. When the heart is displaced to the 
right, the degree of dullness will depend upon the extent 
to which the heart is in close contact with the chest wall. 

Increase in the area of flatness over the prrecordia 
may be due to changes in the pleura or to consolidation 
of that portion of the lung overlying and surrounding 
the heart. 

It is impossible by percussion alone to determine 
where cardiac flatness ceases and that due to pulmonary 
or pleural change begins. 

Effusion into either pleural investment may cause 
some enlargement of the cardiac area of flatness. 

Influence of Changes in the Pericardium. — Changes in the 
pericardium increases the area of flatness either by 
causing hypertrophy of the heart (adhesive pericarditis) 
or distension of the sac (effusion). Fluid in the peri- 
cardium, collecting in the most dependent portion of 
the sac, causes (a) increase in the transverse diameter 
of flatness and marked dullness to the right of the 
sternum, beginning in the fifth interspace on the right 
side. On the left side the flatness extends upward and 
toward the nipple line. As the fluid increases in 
amount the shape of the area of flatness over the pnecor- 
dia becomes more triangular, with a broad base below 
and blunt apex above. The amount of fluid determines 
the size and shape of the triangle, and causes the area of 
deep-seated dullness to be replaced by flatness, sur- 
rounded by a zone of tympanitic pulmonary resonance. 



261 THE CIRCULATORY SYSTEM, 

The resonance over the sternum is also changed when 
the fluid in the pericardium exerts pressure on it. 
Pneumo-pericardium causes the cardiac flatness to be 
replaced by a low-pitched tympanitic resonance. 

Influence of Cardiac Changes. — Increase in the size of 
the heart, whether clue to hypertrophy or dilatation, or 
both, increases the area of cardiac dullness to a much 
greater degree than that of absolute flatness, which, as 
before shown, is generally increased by causes external 
to the heart. 

The size and shape of the increase in cardiac dullness, 
or flatness due to cardiac hypertrophy and dilatation, 
vary according as the right or left side is affected. 
Hypertrophy of the left ventricle causes the left border 
of both dullness and flatness to be moved to the left and 
slightly downward. The upper border remains fairly 
constant, while the right border is unchanged. The 
area of dullness over the apex is pointed. When dilata- 
tion and hypertrophy are associated, the area of flatness 
is more quadrangular; the transverse diameter at 
the level of the fourth rib is increased by extension 
toward the left, and the outline over the apex is rounded. 
In extreme dilatation and hypertrophy of the left heart, 
as occurs in insufficiency of the aortic valves, the left 
border of flatness may reach the anterior axillary line. 
and dullness the mid-axillary line. 

In hypertrophy or dilatation of the right side, when 
the ventricle alone is involved, the upper border of flat- 
ness at the level of the fourth rib shows no marked 
increase. The lower left border is carried slightly out- 
ward, and the right border remains at the left margin 
of the sternum. 

When dilatation and hypertrophy affect both ventricle 
and auricle, the dullness may be detected beyond the 
right border of the sternum as high as the fourth costal 
cartilage. Dilatation and hypertrophy of the right heart 
may cause slight change in the sternal resonance, but 
not to the same degree as pericardial effusion, aneurism, 
or mediastinal tumors. 



PERCUSSION. 265 

Percussion of the Aorta. — The great vessels normally 
give very slight and hardly perceptible dullness in the 

second interspaces. When any dullness is detected, it is 
most marked <>n the right side and is rounded in outline. 
Increase of this area is generally due to aneurisnial 
dilatation of the aorta, although mediastinal new 
growths can cause it. 



CHAP TEE XL 

AUSCULTATION. 

Auscultation of the heart furnishes information 

concerning the normal cardiac sounds, their relative (a) 
rhythm, (b) character or quality, (c) points at which 
they are most distinctly heard (maximum intensity), 
(d) areas over which they are audible (areas of dif- 
fusion), (e) variations and modifications, both normal 
and abnormal; (f) abnormal or adventitious sounds 
(murmurs, frictions), etc., and the degree to which they 
replace the normal cardiac sounds. 

Auscultation should always follow inspection, palpa- 
tion and percussion, as the data obtained by these 
methods are differentiated and enlarged by those 
detected by auscultation, while at the same time they 
correct and define variations in the normal sounds and 
the significance of adventitious sounds. 

Methods of Examination. — Both the mediate and the 
immediate methods of auscultation are employed, each 
having its proper field. 

By mediate auscultation, with the ear applied directly 
to the chest, the observer hears not only the sounds of 
the heart, but he also notes the impulse and other tactile 
sensations, and is thus able to gauge more accurately 
the period of the cardiac cycle at which both normal and 
abnormal sounds occur. 

Immediate auscultation, employing a stethoscope, in 
addition to the advantages noted under Auscultation of 
the Lung, is especially valuable in the examination 
of the heart, as it (a) limits the sound heard to that 
portion of the chest Avail covered by the thoracic end 



AUSCULTATION, 267 

of the stethoscope. This is very important, as the 
cardiac orifices arc situated close to each other, and 
it is accessary to determine where both normal and 
adventitious sounds are heard with the greatest inten- 
sity; while with the ear alone we are apt to include 
more than one valve area in the scope of the examina- 
tion, (b) It cuts off external sounds, (c) It intensi- 
fies some of the sounds produced in the heart, especially 
those due to valve action and murmurs. 

In selecting a stethoscope, the following points should 
be observed : 

The binaural forms are mostly used. The advan- 
tages of the rigid ones over those made with flexible 
tubes are increased power of conduction and convey- 
ance of cardiac impulse, as well as sound. The dis- 
advantages are a certain resonating effect, which 
increases the intensity and may change the character of 
the higher-pitched valve sounds and murmurs. In 
order that the stethoscope be a good conductor of sound, 
whether rigid or made of flexible (rubber) parts, the 
interior should be absolutely smooth. The thoracic end 
of the stethoscope should be small, so as to fit closely to 
the surface of the chest and also limit the field of exami- 
nation to a small area. The ear pieces should fit the ear 
without producing pain or discomfort. Usually too 
small ear pieces are selected, which penetrate too deeply 
into the canal. The ear pieces should merely close up 
the wider portion of the orifice. The spring holding 
the ear pieces in place should not be too stiff, and where 
the instrument has to be used for long periods of time 
each day a form of stethoscope should be used in which 
the pressure of the spring can be regulated. 

The examination should be made methodically, and 
those portions of the heart should be first examined 
where the cardiac sounds are most distinct, both as to 
intensity and their relation to the ventricular systole. 

Normal Cardiac Sounds. — Two sounds are produced by 
cardiac action, each having a definite relation to the 



2(58 THE CIECl LA TORY SYSTEM. 

phase of cardiac cycle and differing in time, character, 
position of maximum intensity and area of diffusion. 

First Sound. — The first sound of the heart corre- 
sponds to the ventricular systole, closure of the mitral 
and tricuspid valves and opening of the aortic and pul- 
monary valves, with forcing of the blood stream from 
the right and left ventricular cavities into the pul- 
monary artery and aorta. The first sound of the heart 
is a prolonged, low-pitched, dull sound, which has some 
resemblance to the sound made in the pronunciation of 
the syllable "lubb." 

The cause of the first sound of the heart is still a 
matter of dispute. Numerous theories have been 
advanced, but no one of them has been universal lv 
adopted. The consensus of opinion is that the first 
sound of the heart is composed of two elements : (a ) 
The muscular element, due to the contraction of the 
cardiac muscle and its impact on the chest wall, giving 
the prolonged, dull, low-pitched quality. (b) The 
valve element, due to the closure of the mitral and tri- 
cuspid valves and stretching of the chorda? tendinea? and 
papillary muscle, causes the short, sharp and high- 
pitched quality. As will be explained under Modifica- 
tions of Normal Sounds, the first sound will vary accord- 
ing as one or the other of these elements predominates. 

The first sound of the heart is heard most distinctly 
at the region of the apex. At this point both muscular 
and valve elements are present. The muscular element 
predominates, because at the time it is heard the rigidly- 
contracting apex of the heart strikes the chest wall and 
is momentarily held in contact with it, conveying the 
vibrations to the thorax. 

Second Sound. — The second sound of the heart corre- 
sponds to the closure of the aortic and pulmonary valves. 
It is shorter, sharper and higher pitched than the first 
sound of the heart, being somewhat similar to the sound 
produced by the pronunciation of the syllable "dubb." 
It is composed of one element only, the valve sound, 



AUSCULTATION. 



200 



which is short, fcense and snapping, and may be "very 
closely imitated by stretching with more or less sndden- 
aess a piece of cloth or a moistened membrane." 

(Sanson.) 

The second sound of the heart, being composed 
entirely of the sounds made by the closure of the aortic 
and pulmonary valves, is heard most distinctly over the 
base of the heart. 

Fig. 44. 




Diagrammatic representation of the movements and sounds of the heart. 
(After Sharpey.) This diagram shows merely the general relations of the 
several events, and does not represent exact measurements. 

In a heart beating seventy-two times a minute, Foster estimates each 
entire cardiac cycle as occupying about 0.8 sec, of which 0.3 sec. represents the 
duration of the systole of the ventricle, 0.4 sec. the diastole of both auricle and 
ventricle, or the " passive interval," and 0.1 sec. the systole of the auricle. 

Only one "pause" is marked here — sometimes called the " long pause; " 
some writers describe a "short pause" also — indicated in the diagram by the 
small space between the first and the second sound. 



Valve Areas. — Listening over certain portions of the 
chest, the first and second sounds are heard with vary- 
ing intensity and clearness, and it is possible to appre- 
ciate the sounds made at the different valves. The' 
areas at which the valve sounds are best heard are called 



270 



77//: CIRCULATORY SYSTEM. 



valve areas, and are named according to the valve 
whence the sound proceeds — aortic area, pulmonary 
area, tricuspid area and mitral area. The areas do not 
correspond to the anatomical situation of the valves, but 
to points on the surface of the chest, to which the vibra- 
tions made at the valves are conducted with the greatest 
intensity. (Fig- 45.) 

Fig. 45. 




From above downwards, showing the anatomical positions of the pulmonic, 
aortic, mitral and tricuspid valves. The arrow-heads show their respective 
sites of audibility. Shaded portion shows part of left heart projecting beyond 
the right heart. 

The Mitral Area. — The valvular element of the first 
sound, heard at the fifth intercostal space, is that pro- 
duced by the mitral valve. The location of the 
mitral area does not correspond with the anatomical site 
of this valve, which is situated behind the left half of the 
sternum, opposite the insertion of the third left costal 



AUSCULTATION, 271 

cartilage. The conduction of the vibrations made at 
the mitral valve to the apex is through the tense chorda 1 
tendineae and papillary muscle, and the ventricular wall. 

The Tricuspid Area. — The sound made at the tri- 
cuspid valve is heard over the lower end of the sternum. 
Conduction of the sound from seat of production to the 
lower end of the sternum is due to conveyance by the 
chordae tendineae and papillary muscle on the right side 
to that portion of the right ventricular wall which is in 
close contact with the lower left edge of the sternum. 

The Aortic Area is in the second right intercostal 
space, close to the sternum, and the second right cartilage 
has been called the "aortic cartilage." The aortic valve 
is situated lower than this area, being behind the left 
half of the sternum to the left of the right third inter- 
space. The vibrations made at the aortic orifice are 
conveyed to the aortic area through the tense walls of the 
aorta, which at this point come closely in contact with 
the chest wall. 

The Pulmonic Area is at the second left intercostal 
space, close to the sternum, and corresponds more nearly 
than do the other areas to the anatomical site of the 
valve, which is slightly lower under the third intercostal 
cartilage, extending slightly into the second interspace. 

Modifications of the Cardiac Sounds. The cardiac 

sounds may be modified (a) in intensity, which may be 
increased or diminished, and (b) in rhythm, which con- 
cerns the duration of the pause which separates the 
sounds. 

(a) Changes in Intensity. — This may involve both 
sounds in nearly equal proportions, or it may affect only 
one sound. Normally, the intensity of the first and 
second sounds of the heart bear a definite relation to 
each other. The intensity of the sounds may be rela- 
tively increased or diminished without indicating any 
pathological change in the heart, as the intensity is 
largely dependent upon the degree of endocardial and 
blood pressure. The increase or diminution affecting 



272 THE CIRCULA Toil Y SYSTEM. 

both sounds should always be considered in connection 
with the tension and compressibility of the pulse. 

The cardiac sounds vary normally within certain 
limits. In the young the first sound is shorter, higher 
pitched and more ringing in character, with a greater 
prominence of the valvular element than in the adult; 
Avhile the second sound, heard over the pulmonic area, 
is louder than the aortic. After. middle life the first 
sound is duller, more prolonged and lower pitched, the 
mitral and tricuspid elements being relatively less 
prominent, while the aortic sound becomes more accen- 
tuated and is louder than that heard in the pulmonic 
area. 

In adult life the first sound varies greatly. "In thin, 
nervous people the first sound is high pitched, short and 
more ringing in character. In the robust and vigorous 
it is low pitched, prolonged and rumbling, while in the 
fat and indolent it is indistinct and short." 

The cardiac sounds are modified (1) by those condi- 
tions which increase or diminish the conduction of the 
sounds to the surface, as (a) thickness or thinness of the 
soft parts, (b) condition of the bony thorax, (c) changes 
in the lung and pleura, (d) changes in the pericardium ; 
(2) by changes in the circulatory system. 

Increase iint Intensity. — Both sounds of the heart 
are increased in intensity (a) when the thorax is thinly 
covered by soft parts ; (b) when the bony thorax is 
flexible and readily thrown into vibration; (c) when, 
through changes in the pleura or lungs, the heart is 
uncovered to a greater extent than normal; (d) when 
the pulmonary tissue that normally covers the heart is 
rendered more homogeneous by consolidation and the 
cardiac sounds are conveyed to the surface with a 
peculiar distinctness, the valvular element being espe- 
cially prominent. Cavities with tense walls and 
pneumo-thorax also cause increased conduction of the 
normal heart sounds. (e) Adherent pericardium 
causes increase in the cardiac sounds, due both to 



AUSCULTATION. 273 

increase of power of conduction and to secondary 
changes induced in the heart muscle. 

Increase in intensity may be due to conditions of the 
circulatory system. 

First Sound. — The intensity of the first sound may be 
increased both in the muscular and valvular elements or 
only in one. In cardiac overaction, and associated with 
low tension in the blood-vessels, as occurs in fevers, 
physical exertion, mental and emotional excitement and 
in Grave's disease, the first sound is high pitched and 
short, and the valve element is most marked. When 
cardiac hypertrophy is present (compensating), and 
when cardiac overaction is associated with high tension 
in the blood-vessels, the muscular element predominates 
and the sound is dull, prolonged and booming. When 
cardiac hypertrophy ceases to be compensating, the first 
sound, although more intense than normal, becomes 
short, sharp and "flapping/ 3 the valvular element being 
most pronounced. 

Second Sound. — Increase in intensity of the second 
sound of the heart may be due to the accentuation of 
both aortic and pulmonic sounds, or it may be limited 
to one sound. 

Accentuation of the Aortic Sound. — Accentuation of 
the aortic sound is usually dependent upon increased 
pressure within the aorta, which causes the valves to 
close with greater tension and suddenness than nor- 
mally. The increased pressure within the aorta may be 
transient^ as when due to increased cardiac action or to 
obstruction to the flow of blood from the arteries and 
capillaries, as spasm from chilling of the surface, nerv- 
ous shocks, etc. ; or it may be permanent, as occurs in 
cardiac hypertrophy with dilatation and in arterial 
sclerosis, kidney disease, etc. The aortic second sound 
is usually accentuated in pregnancy, because of the 
marked increase in blood mass. Accentuation of the 
aortic second sound is usually associated with a corre- 
sponding increase in the intensity of the first sound. 
18 



274 THE ( 'IRCl r LA TOR V SYSTEM. 

This relation is frequently disturbed by the muscular 
power of the heart becoming insufficient, when the 
second sound becomes accentuated and the first sound 
grows progressively weaker and feebler. This associa- 
tion is always a grave symptom. 

As the aortic sound is normally weaker than the pul- 
monic sound until middle adult life, the intensity of 
these two sounds must he compared in order to detect 
changes in the normal relative intensity. After middle 
adult life, normally, the aortic sound approaches more 
nearly that of the pulmonic, and the latter becomes more 
intense. 

Accentuation of the Pulmonic Sound. — The sound 
over the pulmonic area is accentuated by conditions 
which raise the blood pressure in the pulmonary artery, 
as acute and chronic congestion of the lungs, acute 
inflammatory diseases, amemia, and obstructive diseases 
of the lungs (emphysema, fibroid induration). As will 
be shown later, increased tension in the pulmonary 
artery is associated with corresponding hypertrophy of 
the right ventricle. When endo-ventricular pressure in 
the right ventricle is raised above a certain point, insuffi- 
ciency of the tricuspid valve occurs (safety-valve 
action), and there ensues a corresponding diminution 
in the accentuation of the pulmonic sound. 

Dimixutiox ix Ixtexsity. — The cardiac sounds are 
diminished in intensity by (1) those conditions which 
interfere with conduction to the surface, as (a) when 
the thorax is thickly covered with adipose tissue ; (b) 
when the bony thorax is rigid ; (c) when the heart is 
separated from the chest wall by distended lung tissue 
(emphysema) or displaced by effusions into the pleural 
cavity; (d) by effusions into the pericardium and 
piieumo-pericardium. In these conditions the character 
of the sounds is muffled (2) by changes in the heart 
itself. 

First Sound. — The intensity of the first sound of the 
heart is diminished by all conditions of muscular feeble- 



AUSCULTATION. 275 

Hess, both relative, as when hypertrophy is no longer 
compensating, and absolute, as degenerations of the 

cardiac muscle. The sound in these conditions is short, 
sharp, and the booming character is laekingand replaced 
by a peculiar "flapping' 5 quality, dependent upon the 
valve element. 

The Second Sound. — The aortic sound is diminished 
in intensity by (1) conditions which cause low blood 
pressure, decrease in the aortic recoil, and due to 
(a) feeble heart action; (b) imperfect or slow filling of 
the aorta, as occurs in aortic stenosis, mitral stenosis 
and mitral regurgitation; (c) loss of blood mass from 
hemorrhage, diarrhoea, etc., (d) or increased rapidity of 
How from the arteries and capillaries. (2) Changes in 
the valves themselves, diminishing their elasticity, as 
in endocarditis. 

The pulmonic sound varies within much narrower 
limits than does the aortic, as the pressure within the 
pulmonary artery is more uniform. Marked diminu- 
tion in the pulmonic second sound is generally indicative 
of failure of the right ventricle. 

Changes in Rhythm. — The rhythm of the heart 
may be disturbed by alterations in (1) the relative time 
of the pause. When the heart beat is increased in fre- 
quency, in proportion to the rate of the heart, there is a 
corresponding shortening of the pause between the 
second and first sounds of the heart (diastole), but this 
is never sufficiently marked to disturb the normal 
rhythm. 

(2) In embryo-cardia, in which the two sounds follow 
each other at equal intervals, giving the peculiar tick- 
tack character of the foetal heart. This condition is 
generally indicative of profound muscular weakness, 
and occurs in the terminal stage of cardiac disease and 
impending cardiac failure in typhoid and other acute 
diseases. It is an especially grave symptom in typhoid 
and in Grave's disease. 

(S) (J aula- or Gallop Rhythm. — In this condition 



270 THE CIBCULA TOE V SYSTEM. 

three sounds of the heart arc noted. The three sounds 
may be equally distinct, or the added sound may be of a 
different character and may occur at any period of the 
cardiac cycle. The rhythm is similar to that of the 
footfalls of a galloping horse, hence the name, "gallop 
rhythm," or "bruit de galop." 

(1±) Reduplication of Sounds. — Both the first and 
second sound may be reduplicated or doubled. A 
slight degree of reduplication of the second sound is 
physiological, and can be induced by holding the breath. 
In this condition the temporary heightening of the 
pressure in the pulmonary artery causes tardy closure 
of the pulmonic valves. Doubling of the first sound 
may also occur, but is usually more apparent than real. 
To account for the reduplication of the sounds, many 
theories have been advanced. As the reduplication 
seems to concern chiefly the valvular elements of the 
sounds, it is evidently due to the fact that the time of 
the maximum intensity of the sounds made at the dif- 
ferent valves on one side of the heart does not corre- 
spond to that of their fellows on the other side of the 
heart, being separated by an appreciable interval. 

Abnormal or Adventitious Sounds. Murmurs. — The 
abnormal or adventitious sounds heard over the piwcor- 
dia may be produced (1) within the heart (endocar- 
dial), or (2) in the pericardium, lung or pleura 
(exocardial). 

Endocardial Murmurs. — Endocardial murmurs are due 
to vibrations made at the valve orifices by the movement 
of the blood through them. Normally, the blood passes 
the valvular orifices without any sound being produced 
except the normal first and second sounds. This noise- 
less passage of the blood demands (1) normal anatomi- 
cal conditions at the openings, as far as smoothness of 
surface, relation of the size of the opening, both relative 
and absolute, to the part beyond, and perfect closure of 
the opening by the valves during the normal period. 
(2) A certain specific gravity of the blood, and (3) a 



AUSCULTATION. 277 

definite rapidity and force of the current. Disturbance 
of any one of these factors may be sufficient to break up 
the moving column of blood into "fluid veins" whose 
vibrations are rapid enough to produce a sound or 
murmur when transmitted to the surface of the body. 

Classification of the Murmurs. — Murmurs arc classified 
as (1) organic or valvular, (2) inorganic or non- 
valvular. 

Organic or Valvular Murmurs. — Fluid veins are 
made whenever the blood is forced through a narrow 
portion of the circulatory tract into a part that is larger. 
In the normal heart the relative sizes of the opening and 
cavities of the heart and aorta are such that fluid veins 
are not formed under usual conditions. 

The necessary physical condition for the production 
of fluid veins may be produced by anatomical changes 
at the valve orifices which (a) interfere with the pas- 
sage of blood in normal direction through the opening, 
as narrowing of opening or roughing of the surface 
(obstruction or stenosis) ; (b) which allow of abnormal 
or backward flow (regurgitation), due to imperfect 
closure of opening, from change in valves (absolute 
insufficiency), or to dilatation of opening (relative 
insufficiency). (c) At the aortic and pulmonary 
orifices, increase in the size of the vessel may so change 
the relation between the size of the opening and the 
cavity beyond as to favor the production of fluid veins. 

Inorganic or Non-Valvular Murmurs. — These 
may occur with normal cavities, orifices, and are due 
to (a) changes in the blood, lowering its specific gravity. 
This allows the fluid veins to be more readily formed in 
both normal and pathological conditions of the valves 
and orifices, and also in the great vessels. The specific 
gravity of the blood is lowered in anaemia, hydremia, 
and the murmurs are known as anaemic or hcemic. 

(b) Increase in rapidity and force of the current of 
blood. It is possible for the action of the heart to be 
so energetic and rapid as to produce vibrations 



278 THE CIRCULATORY SYSTEM. 

(inorganic murmurs) at tlio different orifices when they 
are normal in size and structure and the specific gravity 
of the blood is unchanged. The murmurs are known 
as fund tonal or dynamic. 

A certain amount of force is also necessary to produce 
murmurs in pathological conditions of the heart. 

In every case of endocardial murmur one or more of 
the above factors are present in varying degrees, and 
each has an influence in producing certain characteristic 
features of the murmur. 

Characteristics of Murmurs. — The recognition of an 
endocardial murmur and the determination of its origin 
and pathological significance depend upon its (1) 
quality, (2) intensity, (3) time or rhythm, (4) point of 
maximum intensity, (5) area of diffusion, (6) duration, 
(7) permanency and influence of exertion and posture. 

Quality of the Murmur. — Endocardial murmurs 
vary widely in relation to their quality, and it is some- 
times difficult to determine whether or not a slight varia- 
tion from the normal sound is due to the presence of a 
murmur. All murmurs have in a greater or less degree 
a liquid character. In addition to this, they may have a 
peculiar rushing or harsh, blowing sound, which may be 
imitated by the voice in pronouncing the syllables uf, 
uv, us, ush; uz ; or they may have a soft, blowing sound, 
as represented by the syllables with vowel sounds of oo, 
u, all, au; or, again, they may have a rougher, more 
vibrant character, as in uur, orr, arr. At times the 
vibrations may have a musical sound. 

The quality of the sound does not determine whether 
the murmur is organic or inorganic, although lumnic 
murmurs as a rule are of the soft, blowing character. 

The quality of the murmur may change from time to 
time in the individual case, depending upon the changes 
in size and structure of the orifice and valves, the rela- 
tive size and condition of the space into which the blood 
is forced, the varying force of the cardiac action, and the 
presence or absence of anaemia. 



AUSCULTATION. 279 

Entensit? of Murmurs, — The intensity or loudness 
of endocardial murmurs shows greal variability in 
lesions involving the different orifices or in the same 
orifice at different times. 

The intensity of a murmur depends upon (a) the 
force of the Mood current, (b) the size and shape of the 
orifice at which the murmur is made and the state of the 
cavity into which the vibrating blood is thrown, and 
(c) the condition of the blood. 

Systolic murmurs, the force being supplied by the 
ventricular contraction, are usually louder, other things 
being equal, than diastolic murmurs, whose force is due 
to the elastic recoil of the aorta and pulmonary artery. 
In pre-systolic murmurs the force is supplied by the 
auricle. 

The varying degrees of intensity are of important 
diagnostic and prognostic value, as diminution in the 
intensity is frequently the first sign of failing cardiac 
power. On the contrary, gradual increase in the inten- 
sity of the murmur may indicate gradual restoration of 
compensation. 

Tlie size and shape of the orifice influences the 
intensity of the murmur according to the character of 
the vibrations produced. The narrower the orifice in 
proportion to the size of the cavity beyond, the more 
intense is the murmur as a rule. 

The intensity of the murmur is also influenced by 
the character of the circulating blood. When the 
specific gravity is reduced by diminution of the cor- 
puscular elements or by the decrease in proteids 
(hydremia), the murmurs are louder and their quality 
is changed. As the specific gravity blood becomes more 
nearly normal, the loudness of the murmurs decreases. 

The intensity of the murmurs made at the different 
orifices of the heart varies considerably with the posture 
of the patient. Of murmurs made at the mitral and tri- 
cuspid orifices, the obstructive murmurs are loudest 
when the patient is sitting or standing, and become 



2S0 THE CIECULA TOR V 8 YSTKM. 

feebler or disappear when he is lying down. Regurgi- 
tant murmurs at these orifices, on the other hand, arc 
most distinct when the patient is lying flat on the back, 
and become more indistinct as he resumes the upright 
posture. Murmurs made at the aortic and pulmonary 
valves are not influenced to the same extent by posture. 
Aortic regurgitation is loudest when the patient is in the 
recumbent position, and is still further increased if one 
or both arms are raised above the head. Systolic 
anaemic murmurs heard over the base of the heart are 
loudest when in the recumbent position, and their 
intensity is also increased at the end of expiration and 
just at the beginning of inspiration. 

Time or Rhythm. — As endocardial murmurs may be 
produced at any part of the cardiac cycle, the most 
important characteristic is its relation to the normal 
cardiac sounds. As the ventricular systole is the most 
prominent phase of the cardiac cycle, being marked by 
the visible apex beat, the carotid pulse and the first 
sound of the heart, murmurs are timed by it. Mur- 
murs are described as systolic and diastolic. On 
account of the relative length of the diastolic pause, 
those murmurs that are only heard during that portion 
of diastole that immediately precedes the occurrence of 
the first sound have been named pre-systolic murmurs. 

Systolic murmurs may be (1) obstructive, as when 
produced by blood flowing in a normal direction through 
valves that should be open at this period of the cardiac 
cycle — that is, the aortic and pulmonic valves — or (2) 
regurgitant, as when the blood is forced back through 
valves that should be closed, namely, the mitral and 
tricuspid valves. 

Diasystouic murmurs are (1) regurgitant, being 
due to leakage at either the aortic or pulmonary valves, 
which should normally be closed at the completion of 
systole and occurrence of the second sound. 

(2) Pre-systouic murmurs are obstructive, being 
produced at the mitral and tricuspid valves during the 



AUSCULTATION. 



2S1 



auricular systole, which immediately precedes the ven- 
tricular systole and the occurrence of the first sound. 

As the time at which the murmur occurs and its rela- 
tion to the normal sound is most important for diagnosis, 
it is necessary that it be correctly determined. Ordi- 
narily the first sound of the heart is the more easily 
detected than the second sound, and is used to time the 
murmur by auscultation. But whenever it is masked 
by the occurrence of a systolic murmur, the time of the 
different phases of the cardiac cycle should be deter- 
mined by listening over the valve areas, where second 



Fig. 46. 



1st Sound 2nd Sound 



ill' 



Systolic murmur, following first sound. 
1st Sound 2nd Sound 




Systolic murmur, accompanying first sound. 
1st Sound 2nd Sound 




Systolic murmur, replacing first sound. 

sounds are heard with greatest distinctness. With these 
facts well impressed, the time of the abnormal sound can 
be fixed most readily. 

The differential stethoscope is frequently an aid in 
determining the time of a murmur, as it allows of com- 
parison, through the two chest pieces placed at different 
portions of the chest, of the murmur with the first or 
second sound heard at an area uninfluenced by it. 

Murmurs may accompany or take the place of the nor- 
mal heart sounds, and their duration is also measured by 
their relation to the normal cardiac periods. As the 



2S2 



THE CIRCULATORY SYSTEM. 



first sound of the heart is made up of both muscular and 
valvular elements, systolic* murmurs will influence one 
or the other of these elements by accompanying it or 
replacing it, according to the changes that have occurred 
at the orifice and the effect of these lesions on the ven- 
tricular wall and cavity. (Fig. 40.) Diastolic mur- 
murs may accompany, take the place of, or follow the 
second sound; and the presence or absence of the 
valvular sound, and whether or not the murmur follows 
it, determine to a certain extent the condition of the 
orifice of the valves themselves. (Fig. 47.) 



Fig. 47. 



1st Sound 



2nd Sound 



1st Sound 



Diastolic murmur, following second sound. 
1st Sound 2nd Sound 1st Sound 




Date diastolic murmur. 

1st Sound 2nd Sound 



1st Sound 




Pre-systolic murmurs. 

Point of Maximum Intensity and Area of Dif- 
fusion. — The point at which a murmur is most dis- 
tinctly heard determines the orifice at which it is made. 

The points of maximum intensity of the endocardial 
murmurs do not correspond to the anatomical site of the 
valves nor entirely to the valve areas. The conduction 
of murmurs to their points of maximum intensity is 
dependent (a) on the direction of the blood current; 
which produces the murmur, and (b) on the readiness 
with which certain portions of the heart, by reason of 



AUSCULTATION. 



283 



their anatomical relations, transmit the vibrations made 
at the point of obstruction or regurgitation to the sur- 
face. From the point of maximum intensity, the mur- 
mur is transmitted in different directions (area of 
diffusion). The extent and direction of the transmis- 
sion are variable, chiefly according to (a) the strength 
and eh&racter of the vibration producing tbc murmur; 

Fig. 48. 




Mitral pre-systolic murmur. ►{< Apex of heart. 



(h) the method of primary conduction to the surface, 
whether mainly by blood current or solid structures 
(heart, hing, etc.), and (c) to the diffusion over the 
chest from the point of maximum intensity by the bony 
thorax and soft parts. It is necessary to consider the 
point of the maximum intensity and area of diffusion 
of the murmurs made at the different orifices. 



284 



THE CIRCULATORY SYSTEM. 



Murmurs Made at the Mitral Orifice. Mitral Pre- 
systolic Murmurs. — The point of maximum intensity 

is slightly to tlie right of the apox of the heart (loft 
ventricle), whether it is in the normal position or dis- 
placed, and its area of diffusion is, as a rule, very 
slightly beyond the region of the apex. (Fig. 48.) 
The localization of a murmur at the region of the apex 
of the left ventricle is due (a) to the direction of the 
vibrating blood current, which is concentrated at the 

Fig. 49. 




Mitral obstruction. Large arrow direction of current of blood. 



apex by the valves of the narrowed orifice, (b) The 
flaccid condition of the overlying right ventricle pre- 
vents the transmission of the vibrations to the surface 
in that direction, (c) The left ventricle being also in a 
state of relaxation and at its greatest distance from the 
chest wall, the vibrations, conducted to the surface 
through the overlying lung, influence a very small area 
of chest. (Fig. 49.) 



AUSCULTATION. 



285 



A wider area of diffusion of the pre-systolic mitral 
murmur is generally duo either to unusually close rela- 
tion of the apex of the left ventricle to the chest wall, or 

to increased power of conduction on the part of the tis- 
sues surrounding the apex of the heart, or to the 
character of the vibrations. 

The pre-systolic murmur heard at the apex is gener- 
ally due to obstruction at the mitral orifice, although 

Fig. 50. 




Mitral systolic. 



murmurs with this rhythm and localization without 
mitral obstruction have been heard in aortic regurgita- 
tion (Flint murmur), in aortic obstruction and with 
adherent pericardium. 

Mitbal Systolic Murmurs. — The point of maxi- 
mum intensity is at or close to the apex. The area of 
diffusion extends also around this point, and to the left 



280 



THE CIRCULATORY SYSTEM. 



beyond the prsecordia into the axillary region. (Fig. 
50.) The murmur is also hoard in the back, the point 
of maximum intensity being in the left interscapular 
space, a little above the angle of the scapula, opposite 



the spines of the fifth and sixth dorsal vertebrae. 

Fig. 51. 



(Fig. 




Mitral svstolic. 



51.) The area of diffusion is usually limited to the 
left scapular and interscapular regions. 

The murmur made at the mitral valve (situated 
behind the left half of the sternum at the level of the 
fourth interspace) reaches the surface in front over the 



AUSCULTATION. 



287 



apex of the heart and behind in the scapular region by 
two different lines of conduction. (Fig. 52.) Conduc- 
tion to the apex is mainly by the tissues of the left ven- 
tricle, which at the time of the first sound of the heart 
are in a state 1 of extreme tension. The vibrations made 
by the regurgitant stream are transmitted (a) by the 
leaflets of the mitral valve through the tense chordae 
tendinese and papillary muscle to the apex of the left 

Fig. 52. 




Mitral regurgitation. Large arrow shows direction of current of blood. 
Small ariows show conduction of vibration to the apex by chorda? tendineae 
and papillary muscles. 



ventricle, (b) The apex of the left ventricle at this 
time is in direct contact with the chest wall, to which it 
transmits the vibrations of the murmur, (c) From the 
point of contact (the point of maximum intensity) the 
vibrations are conveyed along- the ribs in all directions 
(diffusion). Over the prsecordia they are deadened by 
the right ventricle, so that their diffusion to the right 



2S8 



THE CIRCULATORY SYSTEM. 



and upwards is limited. The vibrations arc conveyed 
by the ribs to the axillary region. The murmur is 

heard over wider area when the Left ventricle is much 
hypertrophied, and the apex is displaced downward and 
to the left, and is in contact with the chest Avail to a 
greater extent. 

Conduction of the mitral regurgitant murmur to the 
scapular region is from the left auricle, which is thrown 

Fig. 53. 




Aortic obstruction. 



into vibration by the stream of regurgitant blood. 
From the auricle the vibrations are transmitted through 
the overlying tissues to the surface. The mitral 
regurgitant murmur heard in the back corresponds more 
nearly to the anatomical site of the valve. 

Mitral systolic murmurs may occur in mitral insuffi- 
ciency, due to acute or chronic endocarditis, causing 



AUSCULTATION, 



280 



deformity of the leaflets, dilatation of the left ventricle, 
or to dilatation of the left ventricle enlarging the mitral 
orifice and causing relative insufficiency of the leaflets 
to close the opening. 

Murmurs Made at the Aortic Orifice. Systolic Mur- 
murs. — The point of maximum intensity as a general 
rule is situated over the manubrium sterni, and not at 

the second right cartilage (aortic area). The area of 

Fig. 54. 




Aortic regurgitation. 



diffusion is upward into the carotids, and laterally along 
the clavicles and over the subclavian arteries. Conduc- 
tion is by the current of blood in aorta to the point of 
maximum intensity. The vibrations are transmitted 
through the walls of the aorta to the manubrium sterni 
and clavicles. (Fig. 53.) 

Systolic murmurs in the aortic region may be caused 
19 



200 



THE CIRCULATORY SYSTEM. 



by conditions that load to tlio production of vibrations 
at the valve orifice itself or in the aorta just beyond. 
At the orifice: (1) Narrowing of the lumen of the 
opening by changes in the valves (stenosis). (2) 
Roughening of the surfaces by vegetations, calcareous 
deposits without diminution in the size of the orifice 
(non-stenotic). In the aorta: (1) Roughening of the 
inner walls of the aorta. (2) Dilatation of the aorta. 

Fig. 55. 




Aortic regurgitation. Arrows show lines of conduction of vibrations. 



Inorganic causes: (1) Functional or dynamic, due to 
increase of cardiac force, as in cardiac overaction caused 
by mental or emotional excitement, physical exertion, 
Grave's disease. (2) Haemic or anaemic. 

Murmurs due to anaemia are heard in the aortic area 
or over the sternum, but are transmitted into the vessels 
of the neck with increasing intensity. 



AUSCULTATION. 



201 



Aortic Diastolic Murmurs. — The point of maximum 
intensity is not, as usually described, at the second 
right intercostal cartilage, but over the sternum and at 
the left edge, opposite the third interspace or fourth 
costal cartilage. The area of diffusion is downward 
along' the sternum, and also to the apex of the left 
ventricle. (Fig- 54.) Conduction of the aortic 1 , 
regurgitant murmur to the sternum at the point of 

Fig. 56. 




Tricuspid obstruction. 



maximum intensity is due' to the intimate relation of 
the aortic cusps with the auriculo-ventricular septum of 

The vibrations made by the 
stream are transmitted from the aortic 
valves through the right auriculo-ventricular septum to 
that portion of the sternum that is in closest contact with 
it, viz. : from the third left interspace to the sixth rib on 



the right side of the heart. 
regurgitant 



202 



THE CIRCULATORY SYSTEM. 



the right side. Conduction of the murmur to the apex 
of the left ventricle is by the regurgitant stream* (Fig. 
55.) The character of the murmur heard at the apex 
may differ greatly from that present over the sternum. 
Variations in the location of the point of maximum 
intensity and area of diffusion are dependent upon the 
cause and the nature of the secondary changes in the 
heart and aorta (see Aortic Regurgitation). 

Fig. 57. 




Tricuspid regurgitant. 



Regurgitation at the aortic orifice may depend upon 
(a) absolute insufficiency of the valves, due to vegeta- 
tions, loss of substance, thickening and distortion of the 
valves, congenital malformation (rare) ; (b) upon rupt- 
ure of the valves ; (c) upon relative insufficiency, as 
when the valves are normal, but insufficient to close the 
orifice on account of dilatation of the aortic ring. 



AUSCULTATION. Wo 

Murmurs Made at the Tricuspid Valve. — Tricuspid 
murmurs are usually most distinct over the lower por- 
tion of the sternum and along' the lower left costal 
cartilages. 

Tricuspid Pre-systoxjc Murmurs. — The point of 
maximum intensity is over the lower portion of the 
sternum, at the upper edge of the ensiform cartilage, 
and the area of diffusion corresponds with the area of 
superficial cardiac dullness. (Fig. 56.) Conduction 

Fig. 58. 




Pulmonic systolic — stenotic. 

to the surface of the vibrations made at the tricuspid 
valve is from that portion of the right ventricle which is 
in direct contact with the sternum. 

The tricuspid pre-systolic murmur is extremely rare, 
and, when detected, is diagnostic of obstruction at the 
orifice, either congenital or acquired. 



294 



THE ( IE( 7 'L. I TOR V SYSTEM. 



Tricuspid Systolic Mubmubs. — The point of maxi- 
mum intensity is at the base of the ensiform cartilage, 
and the area of diffusion from .the point of maximum 
intensity is upward and to the right, not above the third 
rib, and to the left toward the apex of the heart. (Fig. 
5 7.) Conduction of the murmur in these two direc- 
tions is by the regurgitant stream, and by transmission 

Fig. 59. 




Pulmonic systolic anaemic murmur. 



through chordae tendineae to apex, the same as in mitral 
regurgitation. 

Vibrations made at the valve are carried by the 
regurgitant current of blood upward into the auricle 
over which the murmur is heard. The vibrations are 
transmitted to the right ventricular wall by the attach- 
ment of the valve and by the tense chordae tendineae and 



AUSCULTATION. 



295 



papillary muscle. The point of maximum intensity 
and the area of diffusion vary according to the degree of 
hypertrophy and dilatation. At times the murmur 
corresponds in local ion to the mitral area. It is rarely 
heard beyond the prseeordia, and is not carried into the 
axilla nor heard behind in the scapular region. 

Regurgitation at the tricuspid orifice results from 

Fig. 60. 




Anaemia, pulmonic systolic. 



insufficiency due to (a) the effects of acute and chronic 
endocarditis, to vegetations, to induration or distortion 
of the valves, and to shortening of the chordae tendinese ; 
(b) from dilatation of the right ventricle and tricuspid 
ring, with relative insufficiency. The dilatation may 
be permanent or transient (safety-valve action). (See 
Regurgitation at Tricuspid Orifice.) 



290 



THE CIRCULATORY SYSTEM. 



Murmurs at the Pulmonary Orifice. Pulmonic Sys- 
tolic Murmurs. — The point of maximum intensity is 
at the left intercostal space, close to the sternum. The 
area of diffusion may be circumscribed around the point 
of maximum intensity, or may extend upward along the 
course of the pulmonary artery and laterally to the left. 
(Fig, 58.) 

The occurrence of a systolic murmur at the pulmonic 
area is extremely common, and may be due (a) to 



Fig. 61. 




Pulmonic diastolic. 



organic changes in the valves, producing obstruction 
(rare), or (b) to narrowing of the lumen of the pul- 
monary artery by changes in the surrounding structures 
or torsion from displacement of the heart ; (c) to 
anaemia, either alone or associated with dilatation of the 



AUSCULTATION. 297 

artery (most commonly). In anscmic murmurs the 
point of maximum intensity and area of diffusion is 
more variable than in those; dependent on stenosis at 
orifice. (Figs. 59 and GO.) 

Pulmonic Diastolic Murmurs. — This murmur is 
very rare. The point of maximum intensity is over the 
pulmonic valve area. The area of diffusion is along the 
left edge of the sternum. It may occur (a) from con- 
genital malformation or ulcerative endocarditis; (b) 
from relative insufficiency caused by dilatation of the 
pulmonary artery or orifice. (Fig- 61.) 

Exocardial Murmurs. A. Arterial Murmurs. — The 
presence over the aorta of the normal cardiac sounds, 
and of murmurs made at the aortic orifice and in aorta, 
has already been mentioned, and will be still further 
considered under diseases of the aorta. 

When the stethoscope is lightly applied to the carotid 
and subclavian arteries, the normal first and second 
cardiac sounds may be faintly heard; the first sound 
weak and low pitched, the second sound louder, higher 
pitched, and snapping, corresponding to its character 
at the aortic cartilage. Over the arteries that are 
further removed from the heart, as the brachial, crural, 
femoral, etc., no sound is normally heard unless the 
pressure of the stethoscope is sufficiently hard to com- 
press the artery when there is heard a systolic mur- 
mur ("pressure murmur"), whose intensity corresponds 
to the degree of narrowing, and which may have a 
musical quality. 

Murmurs heard over the arteries may be produced 
(a) at the cardiac orifice or aorta, and conducted into 
them, or (b) in the blood-vessels at the point where 
heard. 

Systolic murmurs made in the arteries may be due 
(a) to roughening of the inner coat ; (b) to narrowing of 
the lumen, which may be caused by changes in the Avail 
of the artery, as calcareous plates, or due to pressure 
from surrounding structures, as lymph nodes, etc. ; 



298 THE CIRCULATORY SYSTEM. 

(c) to dilatation of the vessel from fevers, acute local 
inflammation, chronic dilatation and vaso-motor condi- 
tions, causing paresis of the vessel itself at certain 
points; (d) to anaemia. Two or more of these causes 
may be combined in any given case. The association of 
localized vaso-motor dilatation with anaemia is particu- 
larly common. 

Over the subclavian arteries a short, blowing, systolic 
murmur ("whiff") is normally heard when the chest is 
fully expanded. This murmur may become constant 
and harsher if the artery is contracted or a sharp bend 
produced by retraction of the apex of the lung or 
pleural adhesions. This subclavian murmur is fre- 
quently mistaken for an aneurismal murmur. 

Diastolic murmubs may be heard in the arteries in 
cases of extensive aortic regurgitation. In rare cases a 
double murmur has been heard in the femoral artery in 
pregnancy without aortic regurgitation. The statement 
has been made that it also occurs in lead poisoning and 
in mitral stenosis. 

B. Venous Murmurs. — A murmur or humming 
sound may be heard over the great vessels above the 
clavicles behind the sterno-cleido-mastoid muscle in 
about fifty per cent, of young persons, the frequency 
diminishing with age. The occurrence of a murmur at 
this site is due to the sharp bend forward in the internal 
jugular vein and its relation to the omohyoid muscle 
(Hamernyk). This murmur is continuous, and varies 
in intensity. It is loudest during and immediately 
after auricular diastole, during inspiration and when 
the patient is sitting or standing, as at this time the 
current in the veins is strongest. It becomes very faint 
or disappears entirely when the patient is recumbent. 
It is loudest on the right side of the neck, and is 
increased by slightly turning the head to the left. 

In anaemic conditions this physiological murmur 
becomes constant, intensified, and in quality more 
musical. It may also be induced by slight pressure 



AUSCULTATION, 299 

over the veins in other regions of the body. The 
anaemic venous hum (bruit du (liable) is differentiated 
from the arterial murmur by being continuous, and the 
intensity not varying with systole of the heart. When 
communication occurs between the artery and the vein 
(arterial varix), a systolic murmur is heard over the 
area involved. 

Sounds Made in the Pericardium. — Normally, the ser- 
ous surfaces covering the heart move noiselessly. When 
the surfaces are roughened audible vibrations are made, 
and the sound is recognized as pericardial by (a) its 
character, (b) its time, (c) its localization and trans- 
mission, (d) modifications that occur by posture and 
pressure. 

The character of the pericardial friction sounds may 
simulate very closely the endocardial murmurs, but 
usually they are of a rubbing, scratching, rasping or 
scraping quality. Friction sound, although dependent 
upon cardiac action, may not coincide in rhythm with 
the different phases of the cardiac cycle, extending as a 
single sound beyond the period of systole or diastole. 
It may occur as a to-and-fro (double) sound, due to the 
motion of both ventricular systole and diastole, or it 
may even have a triple rhythm, due to auricular systole, 
as well as the ventricular action. 

The friction sound may present variations in rhythm 
and quality over different portions of the pra?cordium, 
and those having a murmur ish quality may lead to 
the diagnosis of endocardial murmur. 

Pericardial friction sound is limited to the precordial 
space, although rarely heard over the entire pericardium, 
even in general inflammation of the sac. It may be 
heard over that portion of the pericardium that is 
reflected over the base of the aorta, and be detected as 
high as the second interspace and as far as the left 
nipple. The point of maximum intensity is usually 
over the base of the heart, in the third and fourth inter- 
spaces. 



300 THE CIRCULATORY SYSTEM. 

The important diagnostic feature of pericardial 
sounds is that they give the impression of being made 
close to the surface, and that their intensity and char- 
acter may be modified by posture. When the body is 
thrown forward so that the heart is in closer contact 
with the anterior portion of the pericardium, the 
sounds become more distinctly f fictional in character, 
which lessens as the patient resumes the upright posi- 
tion, and may be absent when he is recumbent. Firm 
pressure with the ear or stethoscope over the pnecordia 
also increases the intensity of the sound. 

Pericardial friction sounds vary in character and 
location from time to time, according to the nature of 
the changes in the sac. 

Pleuro-Pericardial Friction Sounds. — Pleuro-pericardial 
friction sounds may be heard over that portion of the 
pleura that overlaps the heart. This sound is most fre- 
quently heard in the fourth and fifth intercostal spaces. 
The quality and rhythm of this friction sound may 
correspond with that made in the pericardium, but the 
rhythm is disturbed by the respiratory movements, dis- 
appearing with full inspiration and recurring with 
expiration. 

Cardio-Pulmonary Sounds. — A blowing sound, as of a 
murmur, may be produced by cardiac action in the layer 
of lung that is interposed between the heart and the 
chest wall. It is due to the impact of the heart forcing 
air out of the alveoli with sufficient force to produce a 
localized respiratory murmur or puff (cardio-respiratory 
murmur). It is heard most frequently over the apex of 
the heart and along the left border of relative cardiac 
dullness, and is not transmitted in the area of cardiac 
murmurs heard in the same locality. While caused by 
cardiac action, the murmur is not always synchronous 
with the cardiac sounds ; it may be heard during systole 
and for a short time after the occurrence of the second 
sound. The intensity of the murmur is variable, and is 
affected chiefly by the respiratory movements, and also 



AUSCULTATION, 301 

by the posture of the patient. It may be loudest either 
during inspiration or expiration, or may be present only 
when the lungs arc fully inflated and the breath is hold. 
At times, instead of being heard with each heart beat, it 
is only detected with each fourth beat, its rhythm being 
determined by the respiratory cycle. 

Its intensity may be increased by firm pressure with 
the ear of stethoscope over the pra?cordia. 

When the air-vesicles and bronchioles contain secre- 
tion, the cardiac respiratory murmur may be attended 
with fine crackling or moist rales. 



CHAPTER XII. 

DIAGNOSIS OF DISEASES OF THE HEAET. 
VALVULAR LESIONS. 



REGURGITATION AT THE MITRAL ORIFICE. 

Regurgitation at this orifice is the most frequent of 
all valvular lesions, and at the same time that most 
compatible with good physical health. 

Normally, competency at the mitral valve is dependent 
upon (a) perfect coaptation of the valve leaflets; (b) 
control over the position of the valve leaflets through the 
chordae tendinese by the papillary muscle ; (c) contrac- 
tion of the muscle of the ventricle, which reduces the 
area of the auriculo-ventricular opening to one-half the 
size that it has during ventricular diastole, and also 
changes the shape from a circular to a somewhat oval 
form. 

Incompetency may be due to disturbance in manner 
or time of one or more of these co-ordinating factors. 
Coaptation of the mitral leaflets may be interfered with 
(1) by swelling or vegetations (acute or subacute endo- 
carditis), (2) by loss of substance (ulcerative endocar- 
ditis), (3) by thickening, shriveling or distortion, or 
binding together in a manner to prevent closure. (4) 
The fibrous ring to which the valve is attached may be so 
thickened as to interfere with the action of the valves. 
( 5 ) The chords tendineae may be stretched, thickened or 
distorted. (6) The papillary muscles may fail to exert 
the right amount of traction at the right time on the 



DISEASES OF THE BEABT. 303 

chordae tendinese from weakness of the muscles or 
change (dilatation) of the ventricular cavity. (7) The 
size of lie aiiriculo-ventricular orifice may not be suffi- 
ciently contracted at the time of systole, on account of 
fibrous thickening of the ring at the base of the valves, 
flabbiness of the cardiac muscle or dilatation of the left 
ventricle. In this latter condition the valves, though 
normal, are insufficient to close the opening (relative 
valvular insufficiency). 

Insufficiency at the mitral orifice, due to dilatation of 
the ventricular cavity, is a frequent secondary lesion in 
primary aortic stenosis or regurgitation. Imperfect 
ventricular contraction and dilatation of the ventricular 
cavity may be caused by anaemia, and by acute or chronic 
wasting diseases when associated with physical exertion 
or high blood pressure in the aorta. 

Effects of Mitral Kegurgitation. — The effects of mitral 
regurgitation are both immediate and remote, and vary 
in degree according to the amount of blood that is 
regurgitated into the auricle, the force of the current, 
and the extent to which the disturbance of function at 
the mitral orifice is compensated for. The changes 
induced by this lesion can be divided into three stages, 
according as (1) they are limited to the left auricle and 
ventricle; (2) as they extend beyond the left auricle and 
involve the pulmonary circulation and right ventricle; 
(3) when failure of compensation by the right ventricle 
occurs, with regurgitation at the tricuspid valve and 
interference with venous circulation. 

First Stage. Compensation by Left Auricle and 
Ventricle. — The earliest effect of regurgitation is to 
dilate the auricle, which receives the blood from two 
sources: (1) Normal, the flow from the pulmonary 
vein ; (2) abnormal, flow from the left ventricle through 
the mitral valve. 

The increased amount of blood received into the 
auricle during diastole increases its work during systole, 
and hypertrophy occurs; and, as the dilated and hyper- 



•°>04 THE CIRCVLA TOJl Y SYSTEM. 

trophied auricle throws more blood than normally into 
the ventricle during its diastole, the ventricle also 

dilates and meets the increased demands upon it by 
hypertrophy. In this stage the compensation is through 
the dilatation and hypertrophy that occurs simultane- 
ously in both left auricle and ventricle. If the amount 
of regurgitant blood is not large, there is no interference 
with pulmonary circulation ; neither is the blood forced 
back into the pulmonary veins during auricular systole, 
as the openings of the veins are closed, as in the normal 
condition, by muscular contraction, and consequently 
the effects of regurgitation are limited to the left auricle 
and ventricle. 

Second Stage. Compensation" by Right Ven- 
tricular Hypertrophy. — When the amount of 
regurgitant blood is large and the force of the current 
strong enough, dilatation of the left auricle occurs 
beyond the power of compensation. The auricle is 
quickly filled by the blood from the ventricle, and, as the 
pressure in the pulmonary veins is normally low, the 
flow of blood from the lung is interfered with, and con- 
gestion occurs. This congestion causes interference 
with the flow of blood through the capillaries and raises 
the blood pressure in the pulmonary artery, which in 
turn causes the pulmonary valves to close with greater 
tension, and induces hypertrophy of the right ventricle 
as its work is increased, having to empty itself against 
the raised pressure in the pulmonary artery. The 
hypertrophy of the right ventricle compensates for the 
lesion at the mitral orifice, and increases in degree up to 
a point which depends upon the nutrition of the heart 
muscle and the strength of the tricuspid valves. 

Third Stage. Failure of Right Ventricular 
Compensation. — When pressure in the pulmonary 
artery becomes raised to a certain point, compensation 
by the right ventricle may fail in two ways: (1) The 
tricuspid valve may yield to the high endocardial press- 
ure (safety valve action), (2) or the muscular power of 



DISEASES OF THE HEART, 305 

the right ventricle being insufficient to overcome the 
pressure in the pulmonary artery, the ventricle only par- 
tially empties itself during systole. At the next 
auricular systole it is overdistended by the blood 
received in addition from the right auricle. The dila- 
tation of the right ventricular wall increases the 
auriculp-ventricular opening, which becomes too large to 
be closed by the tricuspid valves (relative insufficiency). 
Incompetency at the tricuspid orifice relieves the work 
of the right ventricle, but causes interference with ve- 
nous circulation, resulting in passive congestion of the 
abdominal organs, and later, effusion into the serous 
sacs and cellular tissue. 

Physical Signs. Inspection. — The signs noted on 
inspection correspond to the effects produced by the 
lesion upon the heart and to the secondary changes in 
the lungs and in the pulmonary, venous and arterial cir- 
culations. The severity of the lesion is estimated by the 
extent of these changes. 

First Stage. — When the amount of regurgitation is 
slight, inspection may be negative, or dilatation and 
hypertrophy of the left ventricle may cause the visible 
apex beat to be displaced slightly downward and to the 
left. When mitral regurgitation occurs early in life, 
the apex may be carried to the left nearly as far as the 
anterior axillary line, and there may be bulging of the 
praecordia. 

Second Stage. — According to the degree of right- 
side cardiac hypertrophy, the area of the apex beat is 
increased. It is seen further to the left, and also over 
the lower portion of the praecordia toward the median 
line and in the epigastrium. In marked dilatation and 
hypertrophy of the left auricle, pulsations may be 
present at the second left interspace, dependent upon the 
systole of the auricle. This auriculo-ventricular sys- 
tole may impart a wave-like motion, from above down- 
ward, to the praecordia. 

Third Stage. — When compensation, through hyper- 
20 



306 THE ( 'IR( 7 LA TORY SYSTEM. 

trophy of the right ventricle, fails, and dilatation 
results, a diffused cardiac, impulse is present over the 
entire lower portion of the left side of the thorax, and 
also in the epigastrium. In extreme dilatation of the 
right ventricle, pulsations may be seen from the third 
to the sixth interspaces near the sternum on the left 
side, and in the epigastrium along the border of the ribs. 

Tricuspid regurgitation and dilatation of the right 
auricle may cause pulsations to be seen in the fifth right 
interspace along the sternum, and systolic pulsations in 
the veins of the neck. 

Involvement of the lungs is shown by cyanosis, 
dyspnoea (orthopncea) ; venous stasis by enlargement of 
the abdomen (ascites), changed respiratory movements 
(hydrothorax) and oedema of the extremities. 

PalPxVtio^. — The character of the cardiac action 
detected by palpation corresponds with that noted by 
inspection. 

First Stage. — When dilatation of the left ventricle is 
slight, the apex beat, in addition to being displaced to 
the left and slightly downward, is strong, and the point 
of contact is well defined. In proportion to the dilata- 
tion and hypertrophy, the strength of the impulse is in- 
creased and heaving in character, while the area becomes 
enlarged. ~No thrill will be felt unless mitral regurgita- 
tion is associated with stenosis. 

Second Stage. — The impulse over the lower portion of 
the praacordia is forcible, and the area is diffused, but 
not so well defined. 

Third Stage. — With failure of right-side compensat- 
ing hypertrophy, the impulse becomes more diffused. 
When dilatation predominates, it has a wave-like, indis- 
tinct character, and may be detected to the right of the 
sternum and in the epigastrium. 

The pulse in the first stage shows no alteration. In 
the second stage it may become very irregular. With 
failure of the right heart (third stage), the arteries may 
be improperly filled, and the pulse becomes small and 
irregular in force and frequency. 



DISEASES OF THE HEART. 307 

When incompetency of the tricuspid valve occurs, 
the liver will be found enlarged and extending below the 
free border of the ribs. In extreme cases it will be 
pulsating. Examination of the abdomen will show 

ascites, and effusion into the pleural cavities will cause 
enlargement of the lower portion of the thorax, with 
loss of respiratory movements. 

Percussion. First Stage. — Percussion shows but 
slight increase in the area of cardiac dullness. In 
hypertrophy and dilatation of the left ventricle alone, 
the outline of dullness over the apex is pointed. 

Second Stage. — With hypertrophy of the right ven- 
tricle, the area of cardiac dullness is increased to the 
left at the level of the fourth rib, and the outline at the 
apex becomes rounded. 

Third Stage. — With dilatation of the right ventricle 
and tricuspid regurgitation, there is increase in the 
upper border of flatness at the level of the fourth rib, 
and dullness may be detected to the right of the sternum 
at this point. Over the lower portion of the sternum 
there may be diminution of the sternal resonance; at 
the apex dullness extends to the left and downward. 

Pulmonary Resonance. — In the first and second stages 
the pulmonary resonance is not impaired. In the third 
stage, oedema of the base of the lungs may cause a 
diminished resonance. In the later stages, with effusion 
into the pleural cavity (hydrothorax), flatness is present 
over the lower portion of the chest. The percussion 
area of the liver is also increased. 

Auscultation. — The distinctive sign of regurgita- 
tion at the mitral orifice is a murmur which occurs with 
the ventricular systole, accompanies, replaces or fol- 
lows the first sound of the heart (Tigs. 50 and 51), hav- 
ing its point of maximum intensity at or near the apex, 
and is diffused in all directions, especially to the left, 
to the axillary line or beyond. Posteriorly, it may be 
heard in the left interscapular space, just below spine of 
scapula. 

The quality of the murmur is variable. It may be 



308 THE CIRCULATORY SYSTEM. 

harsh, high pitched and whistling in character, or soft, 
low pitched and blowing. Some claim that it always 
has a more or loss musical quality. It also changes 
from time to time, and is influenced by posture, being 
most marked when the patient is in the recumbent 
position. 

The quality and intensity of the murmur do not indi- 
cate the extent nor character of the lesion, which are 
estimated by the effect upon the heart and changes in the 
normal cardiac sounds, and in the circulatory system. 

First Stage. — In slight regurgitation a murmur may 
not be present, but the first sound of the heart at the 
apex may be prolonged, due to change in the valvular 
element (impure first sound). When a murmur accom- 
panies the first sound which retains its valvular element, 
the amount of regurgitation is small. The distinguish- 
ing sign of this stage is the absence of accentuation of 
the second sound of the heart in the pulmonic area, with 
a normal intensity of the aortic sound ; also the absence 
of right-side ventricular hypertrophy. 

Second Stage. — On the other hand, accentuation of 
the pulmonic second sound is a characteristic sign of 
compensation of the mitral lesion by hypertrophy of the 
right ventricle. It has been claimed that the diagnosis 
of mitral regurgitation cannot be made unless this 
accentuation of the pulmonic second sound is present. 

In estimating the extent of the lesion by the accentua- 
tion of the pulmonic second sound and its relation to the 
aortic, the age of the patient should always be taken into 
consideration; also whether increased tension in the 
pulmonary artery is due to obstructive pulmonary dis- 
ease (see page 274). 

When right-side ventricular hypertrophy compensates 
for the lesion at the mitral valve, the murmur retains a 
fairly definite quality, intensity and duration; also 
auscultation of the lungs does not show evidences of 
pulmonary oedema, although the breath sounds may be 
harsher than normal. 



DISEASES OF THE HEART. 309 

Third Stage. — With failure of compensation, the 

murmur at the apex becomes less intense. Its trans- 
mission to the left is less marked, while the occurrence 
of tricuspid regurgitation causes the murmur to be 
heard over a wider area to the right, it often being 
impossible to separate these two murmurs; at the same 
time the pulmonic second sound diminishes in intensity. 
The mitral murmur in some cases may entirely dis- 
appear, the tricuspid murmur only being heard. In 
proportion to the failure of compensation, the physical 
signs of pulmonary oedema and effusion into the pleural 
cavities occur. 

Diagnosis of the Pathological Condition. — The nature of 
the lesion at the mitral orifice cannot be determined by 
the physical signs alone, although these may be in a 
measure distinctive. When incompetency is due to a 
recent endocarditis, there is very little change in the 
size of the heart, and the murmur is of a soft, blowing 
quality. When the valves are distorted, thickened, or 
perfect coaptation prevented by contraction of the 
chordae tendinese, due to a previous endocarditis, the 
effect upon the left and right heart is more marked, and 
the murmur has a harsh, rough and more musical 
quality. 

According to the degree of interference with the 
valves, the murmur replaces the valvular element of the 
first sound at the apex. 

Incompetency due to dilatation of the left ventricle 
(relative valvular insufficiency) rarely gives a loud, 
high-pitched murmur. When this condition is secondary 
to disease of the aortic orifice, or changes in the arterial 
system, the mitral murmur is much less intense than 
those at the aortic orifice. Age is an important factor 
in determining the nature of the lesion. Under forty 
years of age, uncomplicated mitral regurgitation is 
generally due to a previous endocarditis. Occurring 
after forty-five years of age, it is generally due to 
secondary dilatation, and is associated with the history 



no 



THE CIRCULATORY SYSTEM. 



and physical signs of the primary lesion at aortic orifice 
or in arteries (arterio-sclerosis). 

Functional and /hemic Murmurs in the Mitral Area. 
— Murmurs with the first sound at the apex, that occur 
in anaemia or severe febrile diseases, are generally soft, 
blowing in quality, and are not associated with 
secondary changes in the heart or pulmonary circulation. 
( Fig. 62.) The apex beat is not displaced ; the force is 
weak, not lifting; the second sound over the pulmonic 

Fig. 62. 




Ana?mia — systolic murmur in mitral area. 



area is not accentuated, although there may be a soft, 
blowing murmur (Fig. 63), and the tension of the 
radial pulse is unaffected. 

Murmurs of this character may occur during acute 
febrile diseases, especially rheumatism, and be due to 
acute endocarditis affecting; the mitral valve, or to tern- 



DISEASES OF THE HEART. 



3 1 1 



porary insufficiency resulting from cardiac muscular 
weakness (myocarditis). It is impossible to determine 
whether these murmurs are organic or functional at first 
examination, and their nature can only be decided by 
noting the changes that occur in the murmur and the 
effect on the heart and circulation. 

Aortic stenosis may be attended by a murmur thai is 
hoard at the apex, with a quality different from that 

Fro. 63. 




Anaemia, systolic murmur in mitral and pulmonary areas. 



present at the base o£ the heart, and simulating the 
murmur of mitral regurgitation. This murmur is not 
transmitted to the axilla nor associated with accentua- 
tion of the pulmonic second sound. 

Differential Diagnosis. — Exo-cardial murmurs may 
simulate those of mitral regurgitation. Pericardial 



312 THE CIRCULATORY SYSTEM. 

friction sound may bo localized at the apex, and be 

synchronous with the first sound of the heart. It is 
differentiated from the endocardial murmur by changes 
in the intensity and character caused by pressure and 
position, and it is not transmitted beyond the apex heat 
nor heard behind in the interscapular space. 

Pleuritic friction sounds generally have more or less 
of the friction quality, and are influenced also by press- 
ure and position, and their rhythm is more dependent 
upon respiratory than cardiac action. 

Cardiorespiratory murmurs are also influenced by 
the respiratory movements, being intensified during 
inspiration, and generally inaudible at the end of expira- 
tion. The point of maximum intensity does not corre- 
spond to the apex of the ventricle, but is somewhat 
removed from it. The murmur does not replace the 
first sound of the heart nor change its valvular character. 
It is also influenced by the position of the patient, being 
most marked in the recumbent position, although this 
is not an invariable rule. 

STENOSIS AT THE MITRAL ORIFICE. 

Obstruction at the mitral orifice may occur as an 
isolated lesion, but it is usually associated with regurgi- 
tation. 

formally, with ventricular diastole the mitral orifice 
enlarges to twice the size that it has during systole, and 
the relaxation of the papillary muscles allows free open- 
ing of the leaflets. The flow of blood through the 
opening is due to three forces that are operative at 
different periods of the ventricular diastole: (1) The 
aspirating or suction force of the dilating ventricle. 
This force is most marked during the first period of 
ventricular diastole, and gradually decreases as the 
ventricle becomes distended. (2) Pressure of blood in 
the auricle and pulmonary veins. This is most marked 
also at the beginning of diastole. (3) Auricular sys- 



DISEASES OF THE HEART. 313 

fcole, which completes the emptying of the auricle, and 
occurs just before the first sound of the heart. 

Narrowing of the mitral orifice may he due to changes 
that involve the auriculo-ventricular ring, interfering 
with the normal enlargement of the opening during 
diastole, or they may involve the leaflets or the chords 
tendineae. These changes are generally secondary to 
endocarditis. 

The earliest change of endocarditis is usually the pro- 
duction of vegetations on the auricular surface of the 
valve, which, while causing no obstruction, render the 
surface rough and allow of the production of a murmur. 
Secondary thickening of the leaflets and the chorda' 
tendineae prevent free motion of the valves, causing them 
to project into the centre of the ventricle, and, while the 
obstruction is slight, fluid veins are formed. Attach- 
ment of the edges of the leaflets may occur, converting 
the valve into a funnel, and producing more or less inter- 
ference with the flow of blood. This condition is 
especially liable to occur in children. More marked 
adhesion and retraction of the valves may occur, so that 
the opening becomes a mere split. 

Effects of Mitral Obstruction. — The changes that occur 
as the result of mitral stenosis are comparatively slow, 
and the effects produced upon the circulatory system can 
be divided into three stages. 

First Stage. — The immediate effect of obstruction at 
the mitral orifice is to increase the work of the left 
auricle, which is met by a compensating hypertrophy. 

When the obstruction to the flow of blood is slight, 
the effect may not extend beyond a simple hypertrophy 
of the left auricle, which is sufficient to force the normal 
amount of blood into the ventricle and to prevent any 
interference with the pulmonary circulation. 

Second Stage. — When the obstruction is more 
marked, the effect may extend beyond the left auricle 
and involve the pulmonary circulation and the right 
heart. Interference with the pulmonary circulation 



314 THE CIRCULATOR V SYSTEM. 

may occur in two ways, according as the hypertrophy of 
the left auricle is sufficient or insufficient to compensate 
for the obstruction. (1) Hypertrophy of the left auricle 
may be sufficient to close the openings of the pulmonary 
veins and to empty itself at the time of auricular systole, 
and yet pressure in the pulmonary circulation may be 
above normal. This occurs when the obstruction at the 
mitral orifice is so marked that the aspirating force of 
the heart and the pressure in the pulmonary veins are 
insufficient to empty the pulmonary circulation during 
the early portion of diastole. This increases pressure 
in the pulmonary veins, arteries and capillaries, causing 
secondary hypertrophy of the right ventricle, with 
accentuation of the pulmonic second sound. Dilatation 
of the left auricle is not present during this period of the 
second stage, and only occurs when the power becomes 
insufficient to overcome obstruction. 

(2) When the hypertrophy of the left auricle is 
unable to overcome the obstruction, dilatation occurs, 
and with auricular systole the blood is forced from the 
auricle, not only through the obstruction, but also into 
the pulmonary veins, and marked congestion of the lung 
ensues. As was explained under "Mitral Regurgita- 
tion," this interference with pulmonary circulation is 
compensated for by hypertrophy of the right heart. 

During this stage the left ventricle may be normal, 
or, on account of imperfect distension of its cavity dur- 
ing diastole, this cavity may be reduced in size. 

Third Stage. — Failure of right ventricular compensa- 
tion occurs in mitral obstruction under the same condi- 
tions and with the same effects as has already been 
noted, under "Mitral Regurgitation." 

Physical Signs. Ijstspectiox. — The changes noted by 
inspection correspond to change in the position of the 
apex beat and the condition of the circulation. 

In the first stage, there being no increase in the size, 
of the ventricles, the apex beat is in the normal position. 
In children the pulsation of the auricle may be noted in 
the second and third left interspaces. 



DISEASES OF THE HEART. 



3 I 5 



In the second stage, especially during the early period, 
the apex beal is displaced upward and to the left, even 
beyond the nipple line. (I H 'ig. G-L) With dilatation of 
the right ventricle there is increase in the area of visible 
apex beat and extension toward the median lino. When 
the disease occurs in early life, there may be slight 
enlargement of the praecordia. 

In the (lu'rrf stage the apex beat is diffused and indis- 
tinct, interference with the pulmonary circulation 

Fig. 64. 




Displacement of apex upward and to the left in mitral stenosis. 



causes marked cyanosis of the membranes and a dusky 
appearance of the skin. Interference with return 
circulation causes the veins of the neck to become 
prominent, and pulsations are noted when tricuspid 
regurgitation is present. 

Palpation, First Stage. — The apex beat may be 
normal or slightly decreased in force. Over the apex 
beat a thrill may be felt. The characteristic feature of 



33 THE CIRCULATORY SYSTEM. 

the thrill is its sudden termination at the moment that 
the apex beat is felt. The duration of the thrill and its 
length will depend upon the degree of obstruction and 
the force of the current during different periods of 
ventricular diastole. 

The pulse may be normal or show slight emptiness of 
the artery. 

Second Stage. — -Hypertrophy of the right ventricle 
causes the apex beat to be more diffused. Over the left 
intercostal spaces the closure of the pulmonary valves 
may be felt as a shock. The thrill is more marked. 
The pulse may be normal and regular when patient is 
quiet, becoming irregular on exertion. 

Third Stage. — With failure of right-side compensa- 
tion, the apex beat becomes more diffused and wave-like, 
the thrill weaker or absent, or, if present, is felt but for 
a short time before the apex beat. The pulse is small, 
irregular, and the arteries are imperfectly filled. 

When failure of compensation has occurred gradually, 
with long-continued interference with the venous circu- 
lation, increased pressure in the arteries, due to obstruc- 
tion to capillary circulation, may cause hypertrophy of 
the left ventricle, so that the apex beat will be more 
marked than during the earlier stages. 

Percussion. First Stage. — The area of percussion 
dullness is normal. During the second and third stages 
it corresponds to the anatomical enlargement of the 
heart (see Mitral Regurgitation). 

Auscultation. — The diagnostic sign of obstruction 
at the mitral orifice is the presence of a marked vibra- 
tory murmur, which begins an appreciable time after 
the second sound and increases in intensity until ter- 
minated abruptly by the accentuated first sound (pre- 
systolic) ; the point of maximum intensity is at the apex, 
around which it is diffused. 

The above are characteristics of the typical murmur 
of mitral obstruction, but it is subject to variations in 
quality, duration and intensity, dependent upon the 



DISEASES OF THE HEART. 317 

degree and character of the obstruction and the force 
of the current of Mood through the openin 



has been described as rough, rumblii 



b? 



rolling, churning, grinding, blubbering, and may be 
simulated by pronouncing the syllables "rrb," "rrt." 

The most distinctive feature is the short, sharp sound 
that terminates the murmur, which always persists, 
even though the other phases of the murmur are absent. 
It may be the only sign present of mitral obstruction, 
as the murmur is not constant. 

The production of a murmur demands that the blood 
pass through the contracted orifice with a definite 
amount of force. As the rapidity of the passage of the 
blood through the heart varies from time to time, accord- 
ing to the rate of cardiac action, the murmur may be 
absent at one time and present at another. Variations 
in the force of the current also cause a rise and fall in 
the intensity of the murmur. 

The duration of the murmur and its relation to the 
first and second sounds of the heart also vary. When 
the murmur is heard only for a brief period, just before 
the first sound, it is distinctly pre-systolic. The dura- 
tion may be longer, however, so that it occupies the 
major portion of diastole, or in some cases it may be 
heard with greatest intensity almost immediately after 
the occurrence of the second sound; but this murmur 
can never occur with or replace the second sound of the 
heart, (Fig. 47.) 

The presence of a murmur during the different por- 
tions of diastole depends upon the nature of the force. 
When the force necessary to produce the murmur is due 
to auricular systole, the murmur is heard just before 
the first sound. When the constriction is marked and 
the force is supplied by the aspirating action of the 
left ventricle and the tension that exists at the time in 
the auricle and pulmonary veins, the murmur will occur 
earlier in diastole. 

First Stage. — The murmur is harsh in proportion to 



318 



THE < 'IB( 7 LA TOR Y S YSTEM. 



the constriction and the auricular hyperl rophy, markedly 
pre-systolic, and terminated with the accentuated firsl 
sound of the heart, which is clear. In slight stenosis 
the accentuated first sound may only he present, or 
the murmur may be temporarily absent when the patient 
is in bed and the cardiac action is quiet. 

Second Stage. — The murmur is harsh, occurs earlier 
in the diastole, with marked pre-systolic increase in inten- 
sity. The pulmonic second sound is accentuated, and 
there is a tendency to reduplication of the second sound 
over the base of the heart and absence of the second 
sound at the apex. Change in the second sound at the 
base or apex is due to increased pressure in the pul- 
monary artery, with diminished tension in the aorta. 

During this stage, when the power of the left auricle 
is failing, two points of intensity may be noted (double 
crescendo) ; one middiastolic, and the other pre-systolic, 
depending upon the varying force of the blood current. 
(Fig. 65.) Auscultation of the lung during the early 

Fig. 65. 




Double crescendo. Mitral obstructive murmur. 



portion of this type shows a slight harshness of the 
respiratory murmur. Long-continued, high tension in 
the pulmonary circulation later produces signs of cardiac 
pneumonia — brown induration. 

Third Stage. — In proportion to the feebleness of the 
left auricular systole and lowering of the pressure in 
the pulmonary circulation, due to failure of right heart 
compensation, the murmur loses its characteristic rough- 
ness or disappears. Accentuation of the second sound 
is absent. The first sound becomes short, sharp and 
sudden over the tricuspid area ; the soft systolic murmur 
of tricuspid regurgitation may be detected. Over the 



DISEASES OF THE HEART. 319 

lungs, failure of the right heart is shown by the physical 
signs of pulmonary oedema and effusion into the serous 

cavities, as noted under "Mitral Regurgitation." 

Differential Diagnosis. — Murmurs that may be mis- 
taken for that of mitral stenosis are (1) those whose 
points of maximum intensity are at the apex — mitral 
regurgitation, tricuspid regurgitation — and (2) those 
that occur during* diastole — aortic regurgitation (Flint 
murmur), tricuspid stenosis, pericardial (friction) 
murmurs. 

Mitral Regurgitation. — The murmur of mitral 
stenosis increases in intensity up to the occurrence of 
the first sound of the heart ; that of mitral regurgitation 
begins with the first sound, and gradually diminishes in 
intensity. 

The murmur of mitral stenosis is localized at the site 
of the visible apex beat ; that of mitral regurgitation is 
transmitted beyond the prsecordia toward the axilla, and 
is heard also behind. 

Mitral regurgitation and mitral stenosis are fre- 
quently associated. Under these circumstances, when 
both murmurs are j^resent, a harsh, rough murmur is 
heard, culminating with the sharp first sound, which is 
immediately followed by a softer, blowing murmur, 
which is transmitted toward the axilla. 

Tricuspid Regurgitation. — The murmur of tri- 
cuspid regurgitation may be heard with the point of 
maximum intensity just within the apex beat. When 
not secondary to mitral stenosis, its time, its area of 
diffusion and the secondary effects upon the venous cir- 
culation are the distinctive features. When associated 
with mitral stenosis, it follows the first sound of the 
heart, and is soft, blowing in character. Tricuspid 
regurgitation is determined more by the changes in the 
venous circulation than by the presence of the murmur. 

Aortic Regurgitation. — The murmur of mitral 
stenosis may occupy most of the diastolic period. It 
usually begins an appreciable time after the occurrence 



320 THE CIRCULATORY SYSTEM. 

of the second sound, and can never accompany or replace 
it. The murmur of aortic regurgitation, on the oilier 
hand, accompanies, replaces or follows immediately 

after the aortic sounds. 

The murmur of mitral stenosis is suddenly termi- 
nated with the occurrence of the first sound. That of 
aortic regurgitation is most marked at the beginning of 
diastole, and usually fades out before the occurrence of 
the first sound. 

"Flint" Murmur. — This may occur as a marked pre- 
systolic increase of the diastolic murmur, or may occur 
as a separate sound in aortic regurgitation. 

Tricuspid Stenosis. — The time of these two mur- 
murs are identical. Their points of maximum intensity 
may be slightly separated, but usually they are the same. 
The murmurs are also similar in quality and duration 
during the diastolic period. The differentiation is 
extremely difficult, and is made only when the two 
murmurs vary in point of maximum intensity and in 
quality. 

Pericardial Friction Sounds. — Pericardial fric- 
tion sounds, especially when due to adherent pericar- 
dium, may simulate the murmur of mitral stenosis, but 
the sound does not terminate with the apex beat, being- 
carried slightly into the systolic period. 

OBSTRUCTION AT THE AORTIC ORIFICE. 
AORTIC STENOSIS. 

Obstruction to the fiVw of blood through the aortic 
orifice, due to diminution of its calibre, is a rare con- 
dition, but signs somewhat similar to those produced by 
narrowing of the orifice are present when the orifice 
remains of the same diameter as in health. 

True obstruction, or stenosis, at the aortic orifice may 
be caused by (1) contraction of the fibrous ring; (2) 
rigidity of the cusps of the valves; (3) adhesions of the 
borders of the valves, and (4) masses of vegetations. 



DISEASES OP Tin-: iii:.\/n\ 321 

Non-obstructive conditions producing a murmur at 
the aortic 1 orifice may be ( 1 ) roughening of the surface 

of the valves by vegetations, calcareous deposits; (2) 
changes in the size of the aorta (relative obstruction), 

and (3) changes in the specific gravity of the blood 
(hsemic or functional murmur). 

Effect of -Stenosis. — The effects of obstruction at the 
aortic orifice may be divided into three stages, according 
as they are limited to (1) the left ventricle, (2) extend 
beyond the mitral valve and involve the pulmonary cir- 
culation and right ventricle, (3) wheu they extend 
beyond the tricuspid valve and involve the venous 
circulation. 

First Stage. — As the lesions that produce obstruction, 
whether due to endocarditis or secondary changes in the 
aorta, progress slowly, there is a corresponding gradual 
increase in the work of the left ventricle, which is met 
by compensating hypertrophy without any correspond- 
ing degree of dilatation. Dilatation does not occur 
until the left ventricle fails to empty its cavity at each 
systole. This failure may be temporary, as when the 
cardiac rate is suddenly increased. Compensation by 
increased hypertrophy may again occur, but the dilata- 
tion of the cavity remains. 

The effect of the stenosis is limited to the left ven- 
tricle for a variable period until repeated, or extensive 
dilatation of the left ventricular cavity causes imperfect 
action of the papillary muscles and enlargement also 
of the auriculo-ventricular ring and relative insuffi- 
ciency of the mitral valves. The effect upon the arterial 
system is marked, producing a characteristic pulse. 

Second Stage. — When regurgitation at the mitral 
orifice occurs the work of the left ventricle is tem- 
porarily relieved, and there is immediate interference 
with the pulmonary circulation, increased tension in the 
pulmonary artery and compensating hypertrophy of the 
right ventricle. For subsequent changes in this stage, 
and those that occur during the third stage, with failure 
21 



322 THE CIRCULATORY SYSTEM. 

of compensation by the right ventricle (see Mitral 
Regurgitation, page 301). 

In conditions which give a similar murmur, but arc 
non-obstructive, the primary effect on the left ventricle 
and the subsequent changes in the heart are absent. An 
exception to this is where atheroma or loss of elasticity 
of the aorta has preceded the dilatation of the aorta, 
when there is hypertrophy of the left ventricle. In this 
condition dilatation of the aorta may occur, instead of 
regurgitation, at the mitral orifice. 

Physical Signs. Inspection. — The position and 
extent of the apex beat correspond to the changes in the 
size of the heart. 

First Stage. — When there is hypertrophy only of the 
left ventricle, the apex beat may be in the normal posi- 
tion, or, at most, carried slightly to the left, and is well 
defined. When hypertrophy and dilatation are asso- 
ciated, it is displaced to the left and downward, and the 
area is more diffused. 

Second Stage, — The apex beat is seen further to the 
left, and also over the lower portion of the pnecordia. 
Visible pulsations may be present in the third, fourth 
and fifth interspaces (left), and there may be pnecor- 
dial bulging. 

Third Stage. — Dilatation of the right ventricle, ve- 
nous engorgement, and tricuspid regurgitation give a 
diffused, wavy pulsation, with enlargement and pulsa- 
tions of the veins in the neck. 

Paliwtiox-. First Stage. — Palpation gives impor- 
tant information concerning not only the condition of 
the heart, but also the degree of stenosis and the nature 
of the structural changes. The apex beat is character- 
istic. It lacks the sudden, sharp tap of the normal 
heart, and the impulse is slow, labored and sustained, 
terminating with a short, sharp recoil that may give the 
sensation of a slight tap. 

When dilatation is added to hypertrophy, the labored 
and forcing action of the heart is increased, but it does 



DISEASES OF THE HEART. 323 

not have the lifting, heaving impulse of hypertrophy 
and dilatation due to other causes. Over the base of the 
heart an intense thrill may be felt; the point of maxi- 
mum intensity is usually in the aortic area, but it may 
be detected also at the apex. 

The intensity of the thrill does not indicate the 
degree or nature of the lesion, although it occurs most 
frequently when the obstruction is due to fibrous or 
atheromatous thickening of the aortic ring or cusps. 
The intensity of the thrill is more directly connected 
with the force of the current. 

The pulse is of great importance in aortic stenosis. 
Its character, when taken in connection with the changes 
in the heart, determines the extent of the lesions that 
cause the systolic murmur at the aortic orifice. 

In proportion to the degree of obstruction is the vari- 
ance between the slow, labored, but forcible, apex beat 
and the small pulse wave. 

Normally, with ventricular systole the blood is 
rapidly forced into the aorta, which is distended, giving 
to the radial artery the characteristic pulse wave. In 
proportion to the obstruction the blood is slowly forced 
into the aorta during the entire period of systole, so that 
there does not occur the sudden distension of the aorta, 
and the pulse wave lacks the sharp rise and continues 
longer. 

Non-obstructive conditions, producing aortic systolic 
murmurs, do not give this type of pulse. 

The characteristics of the pulse in aortic stenosis are 
well seen in the sphygmographic tracings (Fig. 41). 

The effect of exertion on the pulse is important in 
determining the power of the hypertrophied left ven- 
tricle to compensate for the lesion. When exertion 
increases the frequency and force of the pulse, then 
compensation is perfect, be the obstruction small or 
great. If it causes a long, even and regular pulse while 
the patient is quiet, to become shorter, small and 
irregular in force and rhythm, then the compensation is 



324 THE CIRCULATORY SYSTEM. 

sufficient when the heart is boating slowly, but is inade- 
quate to empty the ventricle when the rate is increased. 

Second Stage. — When regurgitation at the mitral 
orifice occurs, the cardiac impulse is less labored, but 
shorter and more diffused. The thrill over the base of 
the heart becomes less intense or may disappear, and the 
pulse becomes shorter and smaller and is not disturbed 
to the same extent by exertion. 

Third Stage. — The impulse becomes indistinct and 
wavy, the thrill is absent and the pulse is small and 
thready. 

Percussion. — Changes in the areas of cardiac flat- 
ness and relative dullness correspond to the changes in 
the size of the right and left ventricles. During the 
stage of simple hypertrophy of the left ventricle, no 
change in the percussion can be detected. With the 
occurrence of dilatation, the area of deep dullness is 
enlarged to the left and downward. 

Auscultation. — The characteristic si^n of aortic 
stenosis is a systolic murmur, occurring with the first 
sound of the heart at the base, 1 with the point of maxi- 
mum intensity in the second right intercostal space and 
transmitted upward and laterally. A marked feature 
of systolic murmurs made at the aortic orifice is their 
transmission into the great arteries. (Fig. 53.) The 
murmur varies in quality, duration, point of maximum 
intensity and area of diffusion, according to the char- 
acter and extent of the lesion and the secondary changes 
in the heart. 

First Stage. — When the obstruction is slight and due 
to vegetations or recent endocarditis, the murmur is soft, 
and occupies but a portion of the systolic period. The 
point of maximum intensity is at the second right inter- 
costal space, and the area of diffusion is but slightly 
beyond it. The aortic second sound is only slightly 
diminished. 



1 If the murmur is timed by the apex beat or the first sound at the apex, it 
may seem to oecur slightly after the beginning' of systole. 



DISEASES OF THE 11 EMIT. 325 

When fibrous or atheromatous changes have stiffened 
the valves and the aortic ring, the murmur replaces the 
first sound at the base 1 , and is harsh and sawing in char- 
acter, especially if thrill be present. It may persist 
during the entire systolic period. The second sound is 
lnuttted or impure; the point of maximum intensity is at 
or above the second right costal cartilage, and the mur- 
mur is heard over the upper portion of the sternum, 
laterally along the ribs and clavicles, and may be heard 
in the interscapular space behind. 

When dilatation of the left ventricle occurs, the point 
of maximum intensity is at the left edge of the sternum, 
at the junction of the third and fourth costal cartilages. 
A systolic murmur may also be heard at the apex, which 
may be due to conduction of the murmur made at the 
base through the ventricular wall, but usually caused by 
slight regurgitation at the mitral orifice. When due to 
mitral regurgitation, at first the murmur may be only 
present after exertion or other causes that increase the 
cardiac rate. 

Second Stage. — The murmur at the base loses its 
harshness. Its area of diffusion is less, and the murmur 
at the apex becomes more marked ; it is associated with 
accentuation of the pulmonic second sound and with 
other signs of pulmonic congestion, and later with 
those of the third stage — venous congestion and tri- 
cuspid regurgitation (see Mitral Regurgitation). 

Diagnosis of the Pathological Condition. — The diagnosis 
of aortic stenosis from other conditions, causing a sys- 
tolic murmur over the aortic area, is made by the 
association with the murmur (a) the signs of primary 
cardiac hypertrophy of the left ventricle, (b) the 
presence of a thrill, (c) the characteristic contrast 
between the force of the apex beat and the size of the 
pulse. 

Aortic obstruction rarely continues as an isolated 
lesion for any length of time, being usually associated 
with regurgitation. In uncomplicated stenosis the 



32 G THE CIRCULATORY SYSTEM. 

aortic second sound is impure, muffled and lacks the 
norma! tense, valvular element. When regurgitation 
occurs, the aortic sound becomes very feeble, or is 
replaced by the murmur. 

Roughening of the surface of the valves gives a soft 
systolic murmur, which is localized around a point of 
maximum intensity at the second left intercostal space ; 
the aortic second sound is clear, and there is no change 
in the position and force of the apex beat or in the pulse. 
These sounds are identical with the early stage of acute 
endocarditis at the aortic valve, that may ultimately 
produce true obstruction. 

Dilatation of the aorta, altering the correlation 
between the size of the aortic orifice and the cavity 
beyond, frequently causes a murmur. The early 
changes due to atheroma diminish the elasticity of the 
aorta, converting it into a rigid tube, increasing the 
work of the heart, and causing hypertrophy of the left 
ventricle. If the aortic surfaces are also roughened, a 
harsh murmur will be present, the aortic second sound 
will be accentuated, and there will be more marked 
distension and pulsation of the vessels of the neck as a 
result of the loss of distensibility in the aorta. The 
pulse wave will be more sudden, and correspond in 
size and force to the apex beat. When dilatation 
occurs, the murmur becomes softer than that of simple 
aortic stenosis, the second sound is accentuated, the apex 
beat has the prolonged, labored character, and the pulse 
is sudden and short. In dilatation and relaxation of the 
aorta, due to neuro-cardiac conditions (Grave's disease, 
hysteria, etc.), the murmur is soft, blowing in quality, 
and heard over the vessels of the neck ; the cardiac action 
is rapid ; the first sound of the heart is short and sharp ; 
the second sound is clear ; the pulse full and compressi- 
ble, and there are pulsations in the vessels of the neck. 

Differential Diagnosis. Aneurism, — Aneurism of the 
ascending aorta may give a systolic murmur and thrill 
similar to those in aortic stenosis, but the second sound 



DISEASES OF THE HEART, 327 

is increased in intensity, and may be fell as diastolic 
valve shock. There is diminution of the resonance over 
fche upper portion of the sternum, and there is generally 
present pulsation over the upper portion of the sternum, 
and pressure symptoms involving the bronchi and 
nerves. The pulse does not show the characteristics of 
aortic stenosis. 

Hjemic murmurs having their point of maximum 
intensity at the second right intercostal space are heard 
also in the second left intercostal space, the usual site of 
maximum intensity. They are soft, blowing murmurs, 
and are not associated with signs of cardiac hyper- 
trophy. The pulse is short, soft and compressible. 
The skin and mucous membranes have the characteris- 
tic appearance of anaemia. 

Pulmonary obstruction has a systolic murmur, 
with its point of maximum intensity to the left of the 
sternum, but the murmur is not transmitted into the 
vessels of the neck. The aortic second sound and pulse 
are unchanged. 

Patext ductus arteriosus gives a systolic mur- 
mur, with the point of maximum intensity in the second 
left intercostal space. The murmur begins somewhat 
after the first sound (late systolic), and continues 
usually after the second sound. It may be heard over 
the entire upper portion of the chest, but is "never car- 
ried into the vessels of the neck or arms. 7 ' 



REGURGITATION AT THE AORTIC ORIFICE. 

Regurgitation at the aortic orifice is always dependent 
upon structural changes in the valves guarding it, or on 
dilatation of the fibrous ring. Perfect closure at this 
orifice is dependent upon normal elasticity of the semi- 
lunar valves, whose free edges are forced together by 
the pressure of the blood in the aorta at the time of 
diastole. 



> y r2S THE CIRCULATORY SYSTEM. 

Regurgitation may be caused by (1) vegetations on 

the free surface of the valves, preventing perfect coapta- 
tion; (2) loss of tissue due to ulcerative endocarditis; 
(3) the cusps may be thickened, shrunken or deformed 

by sclerotic processes, due to chronic endocarditis or 
secondary to changes in the aorta. 

The sclerotic processes that produce thickening and 
distortion of the cusps, or changes in the aorta, are slow, 
but progressive, so that there is a tendency for the 
insufficiency of the valve to gradually increase. 

(4) Dilatation of the aorta may be so marked as to 
involve the fibrous ring and produce enlargement of the 
aortic orifice, rendering it too wide to be closed by the 
cusps 1 (relative valvular insufficiency). 

(5) Rupture of the aortic cusps may be caused by 
violent muscular exercise. It is doubtful whether 
rupture of a cusp can occur from this cause unless it has 
been previously diseased. 

Effects of Regurgitation at the Aortic Orifice. — The 
effects of regurgitation at the aortic orifice can be 
divided into three stages, according as they are limited 
(1) to the left ventricle and arterial system; (2) as they 
extend beyond the mitral valve and involve the pul- 
monary circulation and right ventricle, and (3) as they 
extend beyond the tricuspid valve and cause interference 
with the general venous system. 

First Stage. — The immediate effect is exerted during 
diastole on the left ventricle and arterial circulation. 
On the ventricle the effect of the regurgitant stream is 
to produce dilatation. The dilating force is due (a) to 
the pressure of the regurgitant current from the aorta, 
and (b) to that in the auricle and pulmonary veins, 
reinforced by auricular systole. The blood is driven 
into the ventricle by the elastic recoil of the aorta, and is 
aspirated also into the ventricle during the early portion 
of diastole by the expanding cavity. When the ventricle 

1 Dilatation of the fibrous ring sufficient to cause incompetency of the valve 
has been denied, but its occurrence must be admitted. 



DISEASES OF THE HEART. 329 

is filled, the pressure in the aorta continues to ad on the 
left ventricle through the incompetent valve, according 
to Pascal's law, and cause still further dilatation. The 
rapid filling of the ventricle from the aorta removes one 
of the normal forces that aids the flow of blood from the 
auricle (see Mitral Obstruction, page 312), so that with 
auricular systole a larger amount of blood is forced into 
the already overfilled ventricle. 

On the aorta an equally marked effect is produced 
during' diastole, according to the extent of the regurgita- 
tion. There is a sudden diminution of the blood press- 
ure, which is felt throughout the entire arterial system, 

The primary effects produced during diastole are fol- 
lowed by secondary changes in the ventricle and orta 
during systole. The increased amount of blood in the 
ventricle augments the work of the heart during systole, 
which is met by a compensating hypertrophy. The 
greater capacity of the ventricle causes a larger amount 
of blood than normal to be driven into the aorta, and the 
hypertrophied muscle propels it with greater force. 
These two factors cause increase in the normal blood 
pressure and overdistension of the aorta and great ves- 
sels during systole, which is followed by almost as 
sudden a fall of blood pressure during diastole, due to 
aspiration into the ventricle. 

The effect of the sudden forcing of an increased 
amount of blood into the arteries causes them to become 
not only dilated, but also elongated and tortuous. This 
effect upon the arteries may extend to the veins and 
capillaries. 

The dilatation of the ventricle during diastole, and 
the hypertrophy of the ventricle and dilatation of the 
aorta during systole must be considered as correlated 
effects of aortic regurgitation. In uncomplicated 
regurgitation they bear a definite relation to each other. 
As the dilating force is constantly acting on the ven- 
tricle, there may be frequent attacks of dilatation, fol- 
lowed by recompensation, before insufficiency at mitral 



o6{) THE ( <IRCl X. 1 TOR Y SYSTEM. 

valve occurs. Under these circumstances the left ven- 
tricle may attain enormous proportions (cor bovinum). 

When obstruction is associated with regurgitation, 
the sequence of effects is disturbed. Hypertrophy of 
the left ventricle is most marked, while dilatation of 
the aorta is less, due to the slowness with which the 
enlarged ventricle empties itself through the constricted 
opening. 

Second Stage. — When the mitral valve becomes 
incompetent through dilatation of the ventricle or 
changes in the cusps of the valves, there is marked 
interference with pulmonary circulation and the func- 
tions of the right heart, causing the consecutive changes, 
as described in Mitral Regurgitation (page 303). 

Incompetency of the mitral valve secondary to aortic 
regurgitation must not be considered as an unfavorable 
complication. Generally it is a conservative process, 
relieving the stress on the right ventricle. When com- 
pensating hypertrophy does not keep pace w T ith dilata- 
tion through imperfect nutrition, or is ruptured by 
intercurrent causes, as physical exertion, disease, etc., 
the constantly acting dilating force tends to overpower 
the contracting power of the ventricle, and death from 
asystole occurs unless regurgitation through the mitral 
orifice takes place, relieving the left ventricle both dur- 
ing diastole and systole. 

Compensation for the aortic regurgitation by hyper- 
trophy of the right ventricle may exist for a long time. 
When it fails (third stage), it is due to the same cause 
that induces it in lesions at the mitral orifice. 

Physical Signs. I^spectio^t. — Inspection of the prse- 
cordia and arteries gives important information, and is 
frequently sufficient for diagnosis. 

First Stage. — When the regurgitation has produced 
but a small amount of dilatation and hypertrophy, the 
apex beat is but slightly displaced, and is localized. As 
the size and power of the heart increase, the apex is car- 
ried further downward and outward, and the visible 



DISEASES OF THE HEART. 331 

impulse becomes more marked, with a diffused heaving 
of the chest and bulging of the prsecordia. In sonic, 
cases the diminution of the size of tin 4 enlarged heart 

during systole and the increased negative pressure are 
sufficient to cause retraction of the chest wall over the 
region of the apex beat, instead of the usual lifting 
impulse. 

Pulsations of the aorta, carotids, subclavians, brachials 
and more peripheral arteries are present in proportion 
to the extent of the lesion. The blood-vessels also stand 
out more prominently, and when they are markedly 
tortuous the pulsations in the more superficial ones have 
a peculiar vermicular appearance. Pulsation in the 
vessels may be strong enough to produce movement of 
the extremities, or even of the head. In well-marked 
cases capillkry pulsation may be present. 

Second Stage. — The apex beat becomes more diffused, 
and is carried further to the left and downward. The 
pulsation in the vessels of the neck are not as: marked. 

Third Stage. — The heaving left impulse is replaced 
by a diffuse apex beat, extending to the epigastrium. 
Systolic pulsations are seen in the jugulars. 

Palpation. — Palpation of the precordial shows the 
apex beat to be changed in position and character, 
according to the relative degree of dilatation and hyper- 
trophy of the left ventricle, and subsequently of the 
right ventricle. 

First Stage.— In hypertrophy with slight dilatation 
(eccentric hypertrophy), the apex beat is displaced 
slightly to the left. The force is increased. In well- 
marked hypertrophy and dilatation the systolic impulse 
is lifting and heaving in character, and may jar the 
entire thorax and give a well-marked thrust if the ribs 
are elastic. Diastolic recoil may be detected, especially 
in cases where there is systolic retraction of the chest 
wall. When dilatation exceeds hypertrophy, the apex 
beat is diffused and lacks force. Diastolic thrill may be 
felt over the base of the heart or diffused over the entire 



332 



THE CIRCULATORY SYSTEM. 



prsBcordia. The pulse of aortic regurgitation is the most 
diagnostic of all the valvular diseases, and is also impor- 
tant in estimating the degree of the lesion. The char- 
acteristic feature of the pulse depends on the sudden 
emptying and collapse of the artery during diastole, 
followed by an equally sudden overfilling during systole, 
so that the highest and lowest points of tension follow 

Fig. 66. 




Double aortic murmur and mitral regurgitation. Second stage. Dotted lines 
show fluoroscopic outline of the heart. 

each other very rapidly. The sphygmographic tracings 
(Fig. 42) show this. The passage of the pulse wave 
under the finger causes a sensation as of a series of hard 
particles passing, and the pulse is described as shotty or 
water-hammer (Corrigan's pulse). Elevating the arm 
intensifies this characteristic by favoring, through 
gravity, the emptying of the artery during diastole. 



DISEASES OF Till-: UEAKT. 333 

The pulse is regular as long as hypertrophy compen- 
sates for the regurgitation. When it becomes unequal 
to this task, irregularity, both in rhythm and force, 
occurs. When the regurgitant stream is small, the 
water-hammer character of the pulse is not marked. It 
becomes progressively more prominent with increase in 
dilatation of the left ventricle, and it is also exaggerated 
when regurgitation is associated with ansemia or any 
condition favoring low resistance in the arteries and 
capillaries. Obstruction at the aortic orifice by inter- 
fering with the sudden emptying of the ventricle causes 
the pulse to be smaller and longer. 

Second Stage. — With regurgitation at the mitral valve 
and hypertrophy of the right ventricle, the apex of the 
left ventricle is displaced from the chest wall. The 
impulse is carried downward, and also toward the 
median line, and may be felt in the epigastrium. 

When regurgitation at the mitral valve takes place, 
the pulse becomes smaller ; with the third stage failure 
of compensation, feeble and irregular. 

Third Stage. — Failure of compensation and dilata- 
tion of the right ventricle cause a feeble, wavy, diffused 
impulse, which is also irregular in force and rhythm. 

Percussion. — The increase in the area of percussion 
dullness corresponds to the changes in the size and shape 
of the heart. First Stage. — When dilatation is slight 
and hypertrophy well marked, the area of dullness over 
the apex is sharply triangular, and extends downward 
and outward. Increase in dilatation causes the apex 
area to become rounded and extend further toward the 
left. There is no change along the left border of the 
sternum until, second stage, right ventricular hyper- 
trophy occurs. Third Stage. — Dilatation of the right 
ventricle may cause dullness to be detected to the right 
of the sternum. Dilatation of the aorta may cause 
increased dullness at the level of the second interspace 
to the right of the sternum. 

ArscTLTATiox. — The murmur distinctive of regurgi- 



334 THE CIRCULATORY SYSTEM. 

tation at the aortic orifice is diastolic, with the point of 
maximum intensity over the sternum or at the left edge 
opposite the third interspace and fourth eostal cartilage, 
transmitted down the sternum to the ensiform cartilage, 

and at times to the apex. It is also heard over the aorta 
and arteries. (Fig. 54.) 

The murmur varies in quality and loudness, point of 
maximum intensity, area of diffusion, and duration, 
according to the character and extent of the lesion at the 
aortic orifice and the secondary changes in the aorta and 
heart 

The quality and loudness of the murmur are 
dependent upon the nature of the opening through which 
the blood regurgitates (whether large or small, rough or 
smooth), and the force of the blood current determined 
by the blood pressure in the aorta. 

Fust Stage. — The murmur may be soft, blowing in 
character, and scarcely audible. When the regurgitant 
stream is forced through a narrow, rough opening with 
great force, the murmur is harsh, grating, sawing and 
audible at times some distance from the patient. \ft "hen 
the opening is large, the murmur is more gushing, and 
rapidly diminishes in loudness. When a murmur that 
has been loud becomes weaker and shorter, it indicates 
low pressure in the aorta, due to failure of cardiac 
power or decrease of resistance in capillaries. 

The duration of the murmur and its relation to the 
normal cardiac sounds are important data in determin- 
ing the nature and extent of the lesion. The longer the 
murmur persists during diastole, retaining the same 
degree of loudness, the smaller is the amount of blood 
that regurgitates through the valves and the slighter the 
effect on blood pressure in the aorta. Murmurs which 
are heard for a short time only during the early portion 
of diastole, and rapidly diminish in loudness, indicate 
free regurgitation. 

The murmur may accompany, follow or take the place 
of the aortic second sound, according to the condition of 



DISEASES OF THE HEART. 33o 

the valves. When the incompetency is due to vegeta- 
tions or deformities limited to one cusp, or when all 

the cusps are involved, but their elasticity is not 
destroyed, the aortic second sound may persist, and the 
murmur will accompany or follow it. Jn such eases the 
regurgitation is generally small, although free regurgi- 
tation may occur with persistence of the second sound. 

When incompetency of the cusps is secondary to 
arterial disease or dilatation of the aorta, an accentuated 
aortic second sound may persist with the murmur. 
When the second sound is absent or the murmur replaces 
it, regurgitation is usually free, and not associated with 
stenosis. 

The point of maximum intensity and the area of dif- 
fusion vary greatly. The murmur may be heard 
loudest in the aortic area, over the sternum, opposite the 
third interspace, at the ensiform cartilage, and at the 
apex, or it may be almost equally intense over the 
entire prsecordia. 

The point of maximum intensity is at the aortic area, 
and associated with persistence of the aortic second 
sound when regurgitation is secondary to thickening or 
atheroma of the aorta. * 

Free regurgitation, with very little diastolic tension 
of the aortic cusps, causes the murmur to be heard 
loudest over the right ventricle at the ensiform cartilage 
(conduction through the ventricular septum) and at the 
apex (conduction by the regurgitant stream). 

Frequently the quality of the diastolic murmur heard 
at the apex differs from that over the sternum. The dif- 
ference is due to the routes by which the vibrations made 
at the valve reach the surface; over the apex by the 
regurgitant stream giving a soft, blowing sound; over 
the sternum by the dense tissue giving a harsher, 
higher-pitched sound. (Fig. 55.) 

Over the carotids and distal arteries, diastolic mur- 
mur is detected in proportion to the freedom of regurgi- 
tation. (Duroziez. ) 



3 3 THE CIRCULA TOR Y SYSTEM. 

A diastolic murmur is heard in addition to the nor- 
mal systolic murmur (pressure murmur) when the 

stethoscope is firmly pressed on the artery. Jt never 
occurs except in free aortic regurgitation, and is 
dependent upon a strong reflux current toward the 
heart. In slight regurgitation it is absent. 

In addition to the diastolic murmur, a systolic mur- 
mur is usually heard in the aortic area and over the 
arteries in well-marked cases of aortic regurgitation. 
The systolic murmur may be due to true obstruction 
or to dilatation of the aorta (relative obstruction), which 
occurs in a greater or less degree in aortic regurgitation. 

When true obstruction and regurgitation are com- 
bined at the aortic orifice, the systolic murmur is harsh, 
and carried into the vessels of the neck with diminished 
intensity; but, in proportion to the obstruction, the 
carotid pulsations are less marked, and the pulse does 
not have the jerking, water-hammer character. 

When the systolic murmur is due to dilatation of the 
aorta, without diminution in the size of the aortic 
orifice, it is soft, blowing at the base of the heart, and 
holds its intensity over the vessels, or may become 
louder ; it is attended with marked pulsation in the 
carotids and the characteristic pulse. The diastolic 
murmur is relatively more intense than the systolic, and 
is especially intense over the carotids and distal arteries. 
The first sound of the heart is booming, and the pul- 
monic second sound is not accentuated. 

Second Stage. — When incompetency occurs suddenly 
at the mitral valve, due to muscular weakness, the 
diastolic murmur at the base becomes less intense; the 
systolic murmur at the base becomes softer, and is not 
transmitted so far into the vessels of the neck. Over 
the apex another systolic murmur is heard, due to mitral 
regurgitation. It has all of the characteristics of that 
condition, and is associated with accentuation of the 
pulmonic second sound. After mitral regurgitation has 
occurred, with temporary relief of the left ventricle, 



DISEASES OF THE HEART, 



recompensation may occur, with persistence of the mitral 
murmur, [ncreased power of the hearl is shown by the 
returning harshness and loudness of both diastolic and 
v stolic murmurs over the base of the heart. 

Third Stage. — With failure of compensation by the 
right ventricle, the murmurs become indistinct or 
absent; there is a diminution of the pulmonic second 
sound, and the tricuspid regurgitant murmur and the 
physical signs of pulmonary congestion and oedema, 
already noted, supervene. 



OBSTRUCTION AT THE PULMONARY ORIFICE OR IN 
THE PULMONARY ARTERY. 

Obstruction of the pulmonary orifice occurring after 
birth, is one of the rarest of lesions, although as a 
congenital condition it is relatively frequent in propor- 
tion to the other cardiac defects, and is often associated 
with patent foramen ovale or other malformations of 
the heart. Although true obstruction is a most uncom- 
mon lesion, the diagnosis of obstruction at the pul- 
monary orifice is frequently made, as a number of 
conditions cause over the pulmonary valve area a systolic 
murmur whose points of maximum intensity and areas 
of diffusion are identical with those of stenosis. 

True obstruction at the pulmonary orifice may be 
due to changes in the cusps, as the presence of vegeta- 
tions, thickening and adhesion of their borders, that 
produce a funnel-shaped opening; or the fibrous ring 
may be contracted. 

The pulmonary artery may be narrowed just beyond 
the orifice by endarteritis. Pressure along the course 
of the pulmonary artery by pleuritic adhesions and 
mediastinal tumors (aneurisms, enlarged glands, malig- 
nant growths, etc.) may cause all the effects of obstruc- 
tion at pulmonary orifice. 

Non-obstructive conditions causing a murmur over 
22 



338 



THE CIRCULATORY SYSTEM. 



the pulmonic area are (1) anaemic conditions, especially 
chlorosis; (2) neuro-cardiac diseases, as Grave's dis- 
ease and allied disorders; (3) altered relation of the 
heart to the chest wall, due to displacement and uncover- 
ing of the heart by retraction of the overlying lung, 
pleuritic changes, etc. 

Effect of Obstruction at the Pulmonary Orifice. — Inter- 
ference with the flow of blood causes the right ventricle 

Fig. 67. 




Pulmonary stenosis, tricuspid, regurgitation, pulsating liver. 

to become hypertrophied. If the obstruction is slight, 
no further effect may be produced. If the endocardial 
pressure is much increased during systole, regurgitation 
at the tricuspid valve occurs, causing both dilatation and 



DISEASES OF THE HEART. 339 

hypertrophy of the right ventricle, interference with the 
general venous return and passive congestion of the 
abdominal organs, with oedema and effusion into the 
serous cavities. Clubbing of the fingers and toes, with 
enlargement and arching of the nails, occur in long- 
continued interference with return circulation. 

Physical Signs. Inspection". — Cyanosis is almost 
always present. If the obstruction is congenital, it is 
most marked (blue baby). When the obstruction occurs 
in early childhood or later in life, cyanosis may only be 
noticed on exertion. Over the prsecordia no change may 
be present unless there is dilatation and hypertrophy of 
the right ventricle, when the apex beat is carried down- 
ward, and is also seen in the epigastrium. With 
secondary tricuspid regurgitation, distension of the veins 
of the neck, and later pulsation in them, may be 
detected. The respiratory movements are increased, 
dyspnoea occurring on slight exertion. 

Palpation. — Over the base of the heart there is felt 
a distinct systolic thrill, with the point of maximum 
intensity at the left edge of the sternum opposite the 
second and third interspaces, which may be diffused 
over a wider area. The apex beat is most marked over 
the site of the right ventricle. The pulse is not affected 
until failure of the right heart, with tricuspid insuffi- 
ciency. 

Percussion. — The area of cardiac flatness is slightly 
enlarged. When the dilatation of the right heart is 
marked, it may be detected to the right of the sternum. 

Auscultation. — The diagnostic sign is a harsh, 
superficial, systolic murmur, with the point of maxi- 
mum intensity at the junction of the second rib with the 
sternum. It may be widely diffused over the upper 
portion of the chest, but is never, heard in the great ves- 
sels of the neck. The second pulmonic sound is indis- 
tinct, or may be absent. The duration of the murmur 
is long, beginning sharply with systole and continuing 
almost to the second sound. The murmur is changed 



340 THE CIRCULATORY SYSTEM. 

but slightly by the posture of the patient. Holding the 
breath causes it to become momentarily more intense, 
and then weaker. Forced inspiration intensifies it; 
forced expiration weakens or annihilates it. (Fig. 58.) 

Non-Obstructive Murmurs in the Pulmonic Area. — These 
have the same time (systolic) and point of maximum 
intensity as the obstruction. 

The ancemic murmurs are soft and blowing; they are 
rarely musical or harsh. They are markedly influenced 
by position, being weaker in the upright and louder in 
the recumbent postures. They are influenced in the 
same manner as are the structural murmurs by respira- 
tion. They are associated with arterial murmurs in the 
carotids and subclavians, or with a venous hum. The 
patient is pale. On exertion a ruddy color may occur, 
but no cyanosis. There is no change in the size of the 
right heart, and they are not accompanied by thrill. 
Frequently in women (for the first three days) after 
child birth a murmur may be heard over the pulmonic 
area. It is apt to have a scratching, crepitant-like 
quality. (Figs. 59-60.) 

In the neuro-cardiac diseases the characteristics of 
the murmur are the same as those due to the anemic. 
The cardiac action is increased, and there is marked 
pulsation in the vessels of the neck. 

Altered Relation of the Heart to the Chest Wall. — 
Displacement of the heart by effusion into the pleural 
cavity frequently causes a murmur to be heard over the 
pulmonic area, which disappears on withdrawal of all 
or part of the fluid. Uncovering of the pulmonary 
artery by retraction of the lung also disturbs its relation, 
and causes a soft, blowing murmur to be present. 
These two conditions are associated with change in the 
pulmonary signs. Pleuritic adhesion, and retraction of 
the lung due to pleuritic or pulmonary changes, may 
cause slight narrowing of the pulmonary artery, as well 
as displacement. The murmur will be associated with 
depression of the thorax, with change in vocal fremitus. 



DISEASES OF THE HEART. 341 

increased area of dullness opposite the fourth rib and 
Bigns of pulmonary and pleural changes. 

Differential Diagnosis. Systolic Murmurs. — Aortic sys- 
tolic murmurs usually have the point of maximum 
intensity to the right of the sternum, or may be localized 
in the pulmonary space. They are heard in the vessels 
of the neck. In aortic obstruction the pulse is. small, 
and the cardiac change is limited during the earlier 
stages to hypertrophy of the left ventricle. 

.1 neurismal Murmurs. — Aneurism may produce a 
systolic murmur and thrill in the pulmonic area, but it 
will be attended with pulsations and increased dullness 
<>ver the upper part of. the sternum and pressure 
symptoms. 

Patent Ductus Arteriosus. — The particular feature 
of the murmur of patent ductus arteriosus is its point of 
maximum intensity, which is further to the left of the 
sternum, and also it continues beyond the second sound. 
It is frequently associated with pulmonic obstruction as 
a congenital condition. 

REGURGITATION AT THE PULMONIC ORIFICE. 

Pulmonic regurgitation due to structural changes at 
the orifice is an extremely rare condition. When present, 
it is either congenial and associated with pulmonic 
obstruction; or, if acquired after birth, is due to 
ulcerative endocarditis or secondary to dilatation of the 
pulmonary artery. In the acquired form the cusps of 
the artery show pathological conditions analogous to 
those described under aortic regurgitation. 

Functional or physiological incompetency of the pul- 
monary valves may occur as a result of dilatation of the 
pulmonary artery, due to high blood pressure secondary 
to mitral disease, or changes in the lung interfering with 
the pulmonary circulation, as emphysema, fibrosis, etc. 
Physiological incompetency may take place under exces- 
sive functional activity of the respiratory organs, as in 



3 4 2 THE CIRCULA TOR Y SYSTEM. 

contests of speed, endurance, etc. When it occurs under 
these conditions, it protects the integrity of the pul- 
monary circulation. The physical signs of this type of 
regurgitation are slight, and usually masked by the 
rapidity of the cardiac action and exaggerated breath 
sounds. 

The Effect of Regurgitation at the Pulmonic Orifice.— 
The effect is to cause primary dilatation, with coinci- 
dent hypertrophy of the right ventricle, and later tri- 
cuspid regurgitation, with its accompanying phenomena. 

Physical Signs. Inspection. — The apex beat is car- 
ried to the left. Pulsations may be seen in the epigas- 
trium and in extreme dilatation of the heart to the right 
of the sternum. Distension of and pulsations in the 
veins of the neck occur with tricuspid regurgitation. 

Palpation. — The apex beat is diffuse, and most 
marked over the right ventricle and close to the sternum 
and in the epigastrium. Over the base of the heart a 
diastolic thrill may be felt. Cardiac dullness is 
increased, and may be detected beyond the right edge 
of the sternum over the site of the pulsation. 

Auscultation. — A diastolic murmur is heard with 
the point of maximum intensity in the second left inter- 
costal space, with the area of diffusion downward along 
the sternum and to the apex of the right ventricle. The 
murmur may be harsh, rasping and superficial, espe- 
cially when associated with pulmonary obstruction, or 
soft and blowing when due to dilatation of the pul- 
monary artery. (Fig. 61.) 

Differential Diagnosis. — Pulmonic regurgitation is 
easily distinguished from aortic regurgitation when the 
two murmurs have their usual point of maximum inten- 
sity and area of diffusion. However, they may coincide 
in these respects. In pulmonic regurgitation the signs 
of hypertrophy and dilatation are limited to the right 
side of the heart ; in aortic regurgitation the left ven- 
tricle is chiefly involved. In pulmonic regurgitation, 
dyspnoea and cyanosis, with clubbing of the fingers, are 



DISEASES OF THE HEART. 3 1-3 

marked, also pulsations are noted in the veins. In 
aortic regurgitation the pulsations in the carotids and 
character of the pulse are distinctive. In pulmonic 
regurgitation a murmur is not heard in the vessels of 
the neck; in aortic regurgitation a double murmur is 
heard in the vessels of the neck and over the arteries. 



OBSTRUCTION AT THE TRICUSPID ORIFICE. 

Obstruction at the tricuspid orifice is one of the 
rarest cardiac lesions. Most of the cases are not recog- 
nized during life. Of the recorded cases, nearly 80 per 
cent, occurred in women. 

The obstruction is usually due to adhesions of the free 
margins of the leaflets, converting the valve into a 
funnel-shaped structure, or reducing the opening to a 
mere slit. 

Effect of Tricuspid Obstruction. — The effect varies 
according to the degree of obstruction, and may be 
limited to the right auricle or extend beyond to the 
venous circulation. When the stenosis is slight, hyper- 
trophy of the right auricle is frequently sufficient 
to overcome the obstruction to the flow of blood through 
the orifice. When the power of the auricle is insuffi- 
cient, interference with the return circulation occurs, 
causing congestion of the abdominal organs and effusion 
into the serous cavities. 

Physical Signs. — The physical signs present in tri- 
cuspid obstruction vary greatly. In some of the 
reported cases they were well marked, and in others 
indistinct. As in mitral obstruction, the murmur may 
be present at one time and absent at another. 

Inspection. — When the obstruction is slight and is 
compensated for by the right auricle, no change is noted. 
Interference w r ith venous circulation is shown by dis- 
tension of the superficial veins, especially of the neck. 
When pulsations occur, they are synchronous with the 



344 THE CIRCULATORY SYSTEM. 

auricular systole. There is also some duskiness of the 
skin and oedema. Effusion into the pleural cavity may 
cause change in the position of the apex heat. 

Palpation. — At times a thrill is felt. Its maximum 
intensity may be over the valve along the left border of 
the sternum, or at the apex of the right ventricle in the 
fifth interspace. It may occur in both locations at the 
same time with nearly equal intensity, or its maximum 
intensity may alternate, being first in one place, then in 
another. The radial pulse shows no change, except in 
marked obstruction, when it is rapid, irregular, small 
and compressible. Cardiac impulse may be normal or 
in marked obstruction, feeble and irregular. 

Percussion. — Very little change is produced, except 
that dilatation of the right auricle may increase the 
transverse area of percussion flatness at the level of the 
fourth rib. 

Auscultation. — The diagnostic sign of tricuspid 
obstruction is a pre-systolic murmur, with the point of 
maximum intensity over the lower portion of the 
sternum at the upper edge of the ensiform cartilage. 
Its area of diffusion corresponds to the area of super- 
ficial cardiac dullness. The murmur may occupy the 
entire diastole, with accentuation just before the systolic 
impulse. (Fig. 56.) 

Differential Diagnosis. — The distinctive features of tri- 
cuspid obstruction are absence of ventricular hyper- 
trophy, marked venous turgescence, the presence of a 
thrill and a pre-systolic murmur limited to the area 
occupied by the right ventricle. On account of its 
frequent occurrence with mitral obstruction, it is 
masked by the signs of that lesion. 

Mitral Obstruction. — Mitral obstruction has also 
a pre-systolic murmur, and inspection shows right ven- 
tricular hypertrophy, and, when venous overfilling is 
present, also hypertrophy and dilatation of the right 
ventricle. 

The thrill is more vibratory in quality, and is located 



DISEASES OF THE HEART. 6w 

at the apex, l)ui its termination by ventricular systole is 
more definite. The murmur, although it may be heard 
during the major part of the diastole, lias a pre-systolic 
accentuation more marked, and the murmur terminates 
with the short, intensified first sound. The maximum 
intensity is at the apex, but it is not diffused widely, 
and is never heard alone the left border of the sternum 
or over the ensiform cartilage (tricuspid area), 

The pulmonic second sound is accentuated in mitral 
obstruction, and indistinct in tricuspid obstruction. 



REGURGITATION AT THE TRICUSPID ORIFICE. 

Regurgitation at the tricuspid orifice occurs under 
two separate conditions. (1) It may be due (a) to 
vegetations on the leaflets, preventing perfect coaptation, 

(b) to thickening, shrinkage or deformity of the leaflets, 

(c) to induration and shortening of the chordae tendinese 
and papillary muscles. These structural changes are 
usually due to endocarditis and pericarditis which are 
likely to involve other valves besides, and are relatively 
rare at the tricuspid valve alone. 

(2) Incompetency at the tricuspid orifice is most 
frequently dependent on dilatation of the right ven- 
tricular cavity and the auriculo-ventricular ring, which 
becomes too large to be closed by the valves. Relative 
valvular insufficiency occurs much more readily at the 
tricuspid valve than at the mitral. There is abundant 
proof that there exists a safety valve action at the tri- 
cuspid orifice, and that slight temporary regurgitation 
occurs whenever the pressure in the pulmonary artery 
reaches a certain height. Under normal conditions, 
the functional or physiological regurgitation that occurs 
under extreme exercise or exertion is temporary, dis- 
appearing with the return of the blood pressure to 
normal. When tricuspid incompetency from dilatation 
of the right ventricle is secondary to persistent high 



34 1 i THE CIRCULA TOE Y 8 TSTEM. 

pressure in the pulmonary artery or obstruction at the 
pulmonary orifice, it is permanent, and represents 
another broken link in the chain of cardiac compensa- 
tion. 

The cause of high blood pressure in the pulmonary 
artery may be obstructive disease in the lungs (emphy- 
sema and fibroid changes) or lesion at the mitral orifice, 
either primary or secondary (see Mitral Regurgitation 
and Obstruction). When the relative insufficiency is 
due to transient increase of pressure in the pulmonary 
artery (as in acute bronchitis, overexertion, etc.), or to 
temporary disturbance of cardiac nutrition (pyrexia, 
toxines, anaemia, etc.), the dilatation may become less 
and the valves again become competent to close the 
orifice with the disappearance of the disturbing factors. 

Effect of Tricuspid Regurgitation. — The immediate effect 
is upon the right auricle, which may become dilated to 
an enormous extent. The secondary hypertrophy is 
never very marked, and is always inadequate to com- 
pensate for the lesion. The great veins become dilated, 
the inferior vena cava more so than the superior. The 
valves protecting the veins at the root of the neck 
become incompetent. Venous stasis causes general 
oedema. One of the earliest effects of tricuspid regurgi- 
tation is enlargement of the liver and the occurrence 
of ascites and hydrothorax. 

Physical Signs. Inspection. — As an isolated lesion, 
the apex beat is displaced inward toward the median 
line, and may be beneath the sternum or in the epigas- 
trium. Impulses due to auricular systole may be seen 
in the third and fourth interspaces to the right of the 
-sternum. When secondary to left-side cardiac disease, 
the apex is displaced downward and outward, and also is 
seen in the epigastric region. When secondary to 
emphysema, distension of the lung causes the epigastric 
pulsation to be specially prominent. Cyanosis is 
usually present. In long-continued interference with 
return circulation clubbing of the fingers occurs. 



DISEASES OF THE HEART. 347 

Systolic venous pulsations are present in the jugulars, 
most marked on the right side. In marked eases pulsa- 
tion (A' the Liver may be seen. The respiratory move- 
ments are increased unless hvdrothorax occurs, when 
there will be loss of motion over the lower portion of 
the thorax. 

Palpation. — Cardiac enlargement corresponds to 
that noted by inspection. When tricuspid regurgitation 
is a primary disease, the epigastric pulsations are weak 
and undulatory. When secondary to cardiac or pul- 
monary changes, the pulsations are more forcible and 
heaving. When the ear is placed over the tricuspid 
area, a characteristic wavy impulse is detected in addi- 
tion to the murmur. Hepatic pulsations are one of the 
diagnostic signs, and must be differentiated from 
impulse transmitted to the liver from the aorta or the 
enlarged right ventricle. Pressure on the liver in tri- 
cuspid regurgitation increases jugular pulsations. 

Percussion. — The cardiac area is enlarged to the 
right. Dullness may be detected beyond the right bor- 
der of the sternum at the level of the fourth rib. 

Auscultation. — The murmur of tricuspid regurgi- 
tation is systolic, soft, blowing, with the point of maxi- 
mum intensity along the sternum at the junction of the 
fifth and sixth costal cartilages. The area of diffusion 
corresponds to the extent of the pra^cordia. It does not 
extend above the third rib nor beyond the apex. The 
intensity of the murmur is increased during expiration, 
and is diminished or absent during inspiration. The 
second sound varies. When tricuspid regurgitation is 
primary, it is weak and indistinct. When secondary to 
increased pressure in the pulmonary artery, the second 
sound is accentuated. (Fig. 57.) 

Differential Diagnosis. — The distinctive features of tri- 
cuspid regurgitation are extension of the cardiac area to 
the right, systolic pulsations in the veins and liver, and a 
soft, blowing, systolic murmur, with the point of maxi- 
mum intensity over the site of the tricuspid valve and 



: > I s THE CIRCULATOR V SYSTEM. 

heard over the praeeordia. It is to be differentiated 
from other lesions characterized by a systolic murmur. 
Mitral Regurgitation. — In mitral regurgitation the 

murmur is heard with the point of the maximum 
intensity at the apex, and it is carried beyond the 
prsecordia to the left into the axilla, and that it is heard 
behind. The thrill is vibratory and distinctly pre- 
systolic. The apex is displaced to the left and down- 
ward. 

Aortic Stenosis. — The systolic murmur is heard above 
the third rib, and is carried up into the vessels of the 
neck. It is also associated with characteristic pulse. 

Pulmonic Obstruction. — In pulmonic obstruction the 
point of maximum intensity and the area of diffusion 
are diagnostic. (Tig. 58.) 



DISEASES OF THE MYOCARDIUM. 

Hypertrophy and Dilatation. 

Hypertrophy of the cardiac muscle may occur in two 
forms 1 — (1) simple hypertrophy, (2) hypertrophy with 

dilatation of the cavity, or eccentric hypertrophy. It 
may be limited to the walls of a single cavity, or may 
be general. Cardiac dilatation is also divided into two 
forms 2 — (1) simple dilatation, in which there is increase 
in the size of the cavity, with thinning of the wall ; (2) 
dilatation with hypertrophy, in which, with enlarged 
size of the cavity, there is increase in the relative thick- 
ness of the heart wall. In both eccentric hypertrophy, 
and dilatation with hypertrophy we have increase in the 
size of the cavity, with increase in thickness of the heart 
muscle. The distinction between these two conditions 
depends upon the relative efficiency of the cardiac mus- 

1 Concentric hypertrophy characterized by increase in thickness in the 
walls of the cavity with diminution of its size is rarely recognized during life. 

2 Atrophic dilatation has been described dependent on wasting of the 
cardiac muscle coincident with increase in size of the cavity. 



DISEASES OF THE HEART. 349 

cular power to the dilatation. When the working power 
of the heart is increased beyond what is needed to over- 
come the cause and effect of the dilatation, it is classified 
as eccentric hypertrophy. When, on the other hand, dila- 
tation is predominant, and the increased nmsenlar tissue 
barely compensates for the dilatation, it is classified as 
dilatation with hypertrophy. 

Physical Signs. — Cardiac dilatation and hypertrophy 
are generally secondary conditions. 

The physical signs present in the different forms are 
fully described under "Inspection/' "Palpation/' "Per- 
cussion" and "Auscultation/' also under the diagnosis 
of the different valvular diseases. 



Acute Myocarditis. 

This may exist in two forms, (1) as an acute 
degeneration of the muscle tissue of the heart dependent 
upon infectious fevers (cloudy swelling, parenchyma- 
tous myocarditis) ; (2) as an inflammatory affection of 
the interstitial tissue of the heart, which may also be 
due to infectious diseases, or may be secondary to acute 
inflammations of the pericardium or endocardium. 

Localized or suppurative myocarditis may result from 
infection from micro-organisms, secondary to suppura- 
tions in distant portions of the body or due to extension 
from infectious endocarditis. 

Physical Signs. — The physical signs present are those 
indicative of defective muscular power, with varying 
degrees of dilatation. The earliest change noted is fee- 
bleness of the cardiac impulse, both to inspection and 
palpation. Auscultation shows gradual diminution in 
the muscular element of the first sound, with accentua- 
tion of the aortic and pulmonic second sounds. When 
dilatation occurs, the murmurs of mitral and tricuspid 
regurgitation may be present. 



350 THE CIRCULATORY SYSTEM. 

Chronic Myocarditis. 

Chronic changes in the myocardium may be due to 
(1) fatty degeneration of the muscle tissue; (2) fibroid 
degeneration (fibroid or interstitial myocarditis) ; (3) 
fatty overgrowth (fatty infiltration or cor adiposum). 

Physical Signs. — The physical signs in disease of the 
myocardium are those of weak heart, "weak in muscle 
power and weak in its resistance to blood pressure f } 
signs of hypertrophy and dilatation are usually present 
in varying degree, according to the cause of the condi- 
tion. 

Inspection. — The apex beat of the heart may be in 
the normal position, or displaced ; when the changes in 
the myocardium are secondary to sclerosis or atheroma 
in the blood-vessels, the apex beat will be displaced out- 
ward and to the left in proportion to the hypertrophy 
and dilatation. With insufficiency of cardiac power, the 
patient shows disturbances of the superficial circulation 
and slight blueness of the extremities. Atheroma of the 
blood-vessels is shown by prominence of the temporal 
and other arteries. In fatty overgrowth there is asso- 
ciated obesity. 

Palpation. — The location of the impulse depends 
upon the presence of hypertrophy and dilatation. In 
fatty degeneration the impulse is feeble and diffused. 
When associated with hypertrophy, especially of the 
fibroid type, the impulse, while heaving, lacks the lifting 
force proportionate to the size of the heart. The pulse is 
weak in comparison to the seeming effort of the heart. 
When cardiac power is insufficient, arrhythmia occurs, 
which may be constant or induced by slight exertion. 

Percussion. — The dimensions of the heart are in- 
creased with hypertrophy and dilatation in all direc- 
tions. When dilatation is predominant, percussion 
dullness extends above the third interspace and to the 
nipple line or beyond it. In fatty overgrowth the per- 
cussion area of the heart is increased. Frequently it is 



DISEASES OF THE HEART. 351 

impossible to map out the heart on account of the thick- 
ness of the superficial tissue. 

Auscultation. — The characteristic sign is a short, 
feeble first sound at the apex, with a relatively louder 
second sound over the aorta. The pulmonic second 
sound is not increased in intensity. Usually there is 
reduplication of the first sound. With the occurrence 
of dilatation and valvular incompetency, soft, blowing 
murmurs are heard in the mitral and tricuspid areas. 

Diagnosis of myocarditis rests upon the above physi- 
cal signs, associated with other evidence of insufficiency 
of muscular power, as dyspnoea, oppression in the chest, 
or anginal pain on exertion and after meals, syncope 
with cardiac irregularity. 



CHAPTER XIII. 

DIAGNOSIS OF THE DISEASES OF THE PERICARDIUM. 

The smooth surfaces of the pericardium, lubricated 
by the normal secretion of the serous membrane, glide 
over each other during the cardiac and respiratory 
movements without producing any vibrations which can 
be detected by palpation or heard as a friction sound. 
The amount of secretion contained in the pericardial 
sac in health varies within very narrow limits, and is 
never present in such quantity as to be detected by 
physical examination. Pericardial diseases produce 
distinctive physical signs, according as the normally 
smooth surfaces are altered so as to produce vibrations 
which may be felt or heard, or the sac is distended by 
fluid. 

Pericarditis. 

According to the nature of the changes in the peri- 
cardial sac, three forms of pericarditis can be recognized 
by physical signs, irrespective of their aetiology. The 
morbid conditions of each form may exist separately or 
may be combined in varying degrees, and due to widely 
differing causes. As a number of non-inflammatory 
conditions of the pericardium may produce changes 
similar to those due to the inflammation, and as the 
physical signs depend upon the altered state of the sac, 
they will be described Avith the different forms of peri- 
carditis. 

(1) Dry, Plastic or Fibrinous Pericarditis.— In this form 
the surfaces may be abnormally dry from diminished 



DISEASES OF THE PERICARDIUM. ->•>•> 

secretion, dependent upon loss of blood or fluid from the 
body, or changes in the serous membrane during the 
early stage of inflammation. Later during the inflam- 
matory an nek the surfaces may be covered with thick, 
tenacious exudate (fibrinous or plastic). The surfaces 
may also be roughened by fibrous, tubercular or malig- 
nant growths. The physical signs will vary according 
to the nature of the change. 

(2) Effusion into the Pericardium, Pericarditis with Effusicn. 
— The fluid poured into the sac may be sero-fibrinous, 
serous, purulent or hemorrhagic. Serous effusion, 
small in amount, may coincide with a fibrinous exudate 
which coagulates on the surfaces, while the more liquid 
element gravitates to the bottom of the sac (sero-fibrin- 
ous pericarditis). The liquid element (serum) of the 
inflammatory exudate may be excessive and rapidly fill 
the pericardial sac without the occurrence of the dry, 
or plastic stage. Serous effusion into the pericardium 
occurs as part of a general dropsy and interference with 
the return circulation (hydro-pericardium), and is 
unattended with any inflammatory changes. It usually 
accompanies effusion into other serous sacs. 

Purulent effusion may occur primarily, as in septic 
disease, or be due to secondary changes in sero-fibrinous 
or serous inflammatory pericarditis. Hemorrhagic 
effusion (hgemo-pericardium) may be inflammatory or 
be dependent upon new growths, blood condition 
(scurvy, purpura), rupture of the heart or of a cardiac 
aneurism. 

The physical signs present in effusion are in propor- 
tion to the amount of fluid and the effect of the enlarged 
pericardium upon the heart and surrounding organs. 
The nature of the fluid does not modify the physical 
signs. 

(3) Pericardial Adhesion. Adherent Pericardium. — This 
is usually secondary to inflammatory diseases of the 
pericardium. It may be limited to a few bands loosely 
stretched between the two surfaces and not interfering 

23 



354 THE CIBCULA TOE Y SYSTEM. 

with the cardiac action; or the two surfaces may be 
closely united, or the sac may be completely obliterated, 
in which case the movements of the heart will be entirely 
or in part restricted and secondary hypertrophy or dila- 
tation with hypertrophy will occur. 

Physical Signs. — As the three forms of pericarditis 
may he variously combined, or follow each other during 
the course of an attack of pericarditis, they Avill he con- 
sidered together. 

Inspection. Dry, Plastic or Fibrinous Form. — 
There is no change in the contour of the praecordia. 
The apex beat is in the normal position, the impulse 
more forcible, due to cardiac irritability. When asso- 
ciated with myocarditis, the impulse is weaker and more 
diffused. 

Second Form. Effusion into the Pericardium. — 
Change in the prsecordia will be in proportion to the 
quantity of fluid and the elasticity of the chest walls. 
The effects on the shape and size of the thorax will be 
most noticed in thin persons and in children, and may be 
masked in stout persons. The apex beat is seen at a 
higher point on the chest wall, according to the amount 
of fluid present. This is not due to elevation of the 
anatomical apex, but to the changed relation of the 
anterior portion of the heart to the chest wall, so that a 
point nearer the base of the heart strikes the chest wall 
and gives the visible and palpable apex beat, (a) Small 
effusions may produce no change in the pra?cordia. The 
apex beat is displaced inward and slightly elevated, (b) 
In medium-sized effusions the intercostal spaces along 
the left side of the sternum, from the third to the sixth, 
are filled out, and may be slightly bulging. The thorax 
over the apex is slightly enlarged, (c) In large effusions 
the bulging over the prsecordia is marked, and the lower 
end of the sternum is pushed out ; the epigastric region 
is more prominent, the costal cartilages and ribs are 
elevated, and the intercostal spaces on both sides of the 
sternum are wider, the normal depressions being absent. 



DISEASES OF THE PERICARDIUM, d55 

The changes in the lower portion of the dies! are due to 
diminished negative pressure within the thorax and 
depression of the diaphragm and liver by the weight of 
the fluid. The visible impulse is usually seen above the 
fourth rib. Jn extreme distension pericardial bulging 
may extend as far as the second rib. 

Enlargement of the pericardial sac causes reduction 
of the negative pressure within the chest, and allows of 
the elevation of the bony thorax and changed relation 
between the ribs individually, and especially between 
the first rib and the clavicle. Ewart has called atten- 
tion to the changed relation between the clavicle and the 
first rib (first rib sign) as important in diagnosis of 
effusion of considerable amount. The left clavicle is 
raised to a higher level, so that the upper edge of the 
first rib on the left side can be felt as far as its sternal 
attachment. When the amount of fluid is sufficient to 
produce a positive pressure, instead of the normal nega- 
tive pressure in the pericardium, cyanosis occurs, also 
pulsations in the veins of the neck, due to auricular 
contraction. 

The effect of posture on the apex beat in effusion is 
the opposite of what occurs in other conditions, causing 
an elevation of the apex beat. When the patient is on 
the right side, the apex beat becomes lower and more 
distinct ; in other conditions it is higher, weaker or 
absent. 

Adherent Pericardium. — Flattening of the chest over 
the lower portion of the pr?ecordia usually occurs. 
Occasionally there is bulging, due to hypertrophy and 
dilatation of the heart. Systolic retraction of the chest 
wall may be limited to the apex and the intercostal 
spaces to the left of the sternum, or to the left half of the 
epigastrium. The respiratory movements are altered 
when extensive pericardial changes are present. With 
inspiration there is loss of expansion over the lower 
portion of the left chest below the horizontal nipple line, 
and drawing in of the end of the sternum. Protrusion 



3 5 G THE CIRCULA TOR Y SYSTEM. 

of the abdomen, and frequently ascites, may occur. The 
apex beat is displaced outward and downward or ele- 
vated as high as the fourth rib, according as the heart 
is hypertrophied or dilated or fixed by adhesions in an 
abnormal position. The apex beat does not vary with 
change in the posture of the patient. The diastolic 
rebound of the heart may be visible. Diastolic collapse 
of the veins is occasionally seen. 

Palpation. Dry, Plastic or Fibrinous Pericarditis. 
— The cardiac impulse may be increased. Friction 
fremitus is felt over different portions of the prsecordia 
in a small proportion of cases ; it is most readily detected 
by making moderate pressure in the intercostal spaces 
with the finger tips. The rhythm of the fremitus 
generally corresponds with the systole, but may extend 
into the diastolic period or be confined to it. It does 
not have a well-defined or stable point of maximum 
intensity, but varies in different cases and in the same 
case at different times, although it is more frequent and 
persistent over the base of the heart. The area over 
which it is felt is usually the circumscribed point of 
maximum intensity; occasionally it is felt over the 
entire prsecordia, and may be perceptible in widely 
separated spots. The fremitus gives the sensation of 
being superficial and produced by the rubbing together 
of dry, rough or sticky surfaces. In acute cases the 
friction fremitus is present for a short time only, and 
varies from day to day in situation, extent and char- 
acter. 

Effusion into the Pericardium. — Friction fremitus, 
usually absent over the lower portion of the prsecordia, 
may be detected above the fourth rib and over the site 
of the great vessels. Cardiac impulse is felt at a higher 
level, and is more diffused according to the amount of 
diffusion. Fluctuation over the prsecordia may be 
present when the amount of fluid is sufficient to give 
positive pressure in the pericardium. Diminution in 
the amount of fluid causes the cardiac impulse to be felt 



DISEASES OF THE PERICARDIUM. 357 

at a lower point, and to become more defined. Removal 
of the fluid is frequently attended with reappearance of 
friction fremitus. 

Adherent Pericardium. — In addition to the abnormal 
movements of the chest wall noted in inspection, the 
cardiac impulse frequently gives the sensation of being 
abnormally close to the chest wall. According to the 
situation and extent of the adhesions and the secondary 
changes in the heart (hypertrophy or dilatation), the 
impulse will be displaced to various portions of the 
prsecordia, and will be strong, diffused or of a more 
undulating character. When adhesions unite the heart 
with the chest wall, diastolic shock is a marked symptom. 

Percussion. Dry, Plastic or Fibrinous Pericarditis. 
— No change in the area of superficial flatness or rela- 
tive dullness is detected unless myocarditis with dilata- 
tion is present. The extreme edge of cardiac dullness 
corresponds closely to the apex beat. 

Effusion into the Pericardium. — The most distinctive 
sign of pericardial effusion is change in the extent and 
outline of the area, of cardiac flatness and dullness and 
their relation to each other. These changes can be 
detected by careful and systematic percussion when but 
a small quantity of fluid is present. The area of flatness 
increases, while that of relative dullness diminishes. 
As the pericardium increases in size, change in the 
interthoracic pressure (negative pressure) allows that 
portion of the lungs which normally covers the peri- 
cardium to retract, so that there is not the gradual 
change from normal pulmonary resonance to cardiac 
flatness. In extreme distension of the pericardium, the 
change in the intrathoracic pressure may be sufficient to 
cause diminution of function in different portions of the 
lungs, with characteristic pulmonary resonance. A 
small effusion causes change in the percussion area, 
most marked at the level of the fifth rib. (a) To the 
left the flatness extends to the site of the normal apex 
beat or slightly beyond. The area of relative dullness 



358 THE CIRCULATORY SYSTEM. 

in this region is decreased, (b) At the right of the 
sternum dullness is delected in the fifth intercostal 
space (cardio-hepatic triangle), and the cardio-hepal ie 
triangle becomes more obtuse (Roteh's sign). As the 
fluid increases in amount, the area of flatness extends 
in all directions, especially laterally, at the lower level 
of the pericardium. With the increase in extent, the 
contour of the pericardial flatness also changes, 
becoming more pyramidal, with the two sides meeting 
the base at nearly equal angles. More marked distension 
causes the lower segment of the pericardium to be more 
globular and the upper portion more cylindrical, so that 
the typical pear-shaped outline obtains. Sternal reso- 
nance is altered by the effusion. As the sac becomes 
filled, the resonance becomes impaired, and is later 
replaced by flatness. The change in loss of resonance 
occurs from below upward, in contradistinction to that 
occurring in aneurism of the aorta. The percussion 
note over the lung is changed according to the amount 
of fluid present. As the fluid increases, the enlarged 
pericardium allows retraction in the overlapping lung 
and diminution of tension, so that the normal pul- 
monary resonance is replaced by a tympanitic quality 
( Skoda' s resonance), which in large effusion may be 
present over the apex of the lung on the left side. 

"Whenever fluid is effused into the pericardium, the 
normal resonance is modified at the left posterior base 
in the most definite way. A patch of marked flatness is 
found at the left inner base, extending from the spine 
for a varying distance outward, usually not quite so far 
as the scapular line, and ceasing abruptly with the 
vertical boundary. Above, its extension is also variable, 
according to the size of the effusion. Commonly it does 
not extend higher than the level of the ninth or tenth 
rib, and here, again, its horizontal boundary is abrupt. 
Its shape is that of a square, and is quite unlike that of 
any dullness arising from pleuritic effusion." (Ewart.) 

Over the liver, the upper limit of both dullness and 



DISEASES OF Till-: PERICARDIUM. : >'"'>• , 

flatness is lowered; the lower edge of the liver is below 
the free border of the ribs in proportion to flic depres- 
sion of the diaphragm. 

Adherent Pericardium. — Changes in thickness of the 
pericardium do not affecl the percussion area. Any 
alteration in size or shape is due to the presence of 
hypertrophy or dilatation of the heart. 

Auscultation. Dry, Plastic or Fibrinous Pericar- 
ditis. — The diagnostic sign of this form is the friction 
sound. The quality of the friction sound varies 
according to the condition of the pericardial surfaces. 
It may be soft and murmurish, simulating the endocar- 
dial murmur; soft, dry, grazing or brushing, as when 
the dry finger tips or pieces of silk are gently rubbed 
together close to the ear; sticky; or harsh, creaking or 
grating, as when new leather is bent. In addition to 
the friction quality, the sensation of being superficial is 
a distinctive feature. The rhythm of the friction 
sound, while dependent upon cardiac movement, is not 
accurately limited to the periods of the normal cardiac 
sounds, but by extending beyond them it gives a double 
or to-and-fro rhythm, which is characteristic of peri- 
cardial friction. The point of maximum intensity is 
not stable, and the sound is not conducted beyond the 
praecordia except in rare cases, when the conduction is 
due to change in the surrounding lung tissue. 

The friction sound may be heard over any portion of 
the praecordia, but its most persistent site is over the 
base of the heart, opposite the third and fourth ribs on 
the left side. The intensity of the sound is influenced 
by (a) pressure, (b) position, and (c) respiratory move- 
ments in a rather characteristic way. (a) Pressure 
over the praecordia causes the friction sound to be heard, 
or, when present, to become more intense and audible 
over a wider area and for a longer period of time; it 
also increases the to-and-fro character, and emphasizes 
its want of synchronism with the normal cardiac sounds. 
(b) Posture. Bending the body forward, so that the 



360 THE CIBCULA TORY SYSTEM. 

heart comes in contact with the anterior portion of 
the pericafdmm, affects the friction sound in the same 
manner as pressure. It intensifies the sound, and 
increases the area over which it is heard, (a) Respira- 
tory movements. The intensity, quality and extent of 
the friction sounds change during inspiration and 
expiration. In some cases the increase in these feat- 
ures occurs during inspiration, and at others during 
expiration. The significant fact is that the sound is 
altered to a marked degree during either inspiration or 
expiration. Variability from day to day in the site, 
rhythm, intensity and quality is a distinctive feature of 
pericardial friction sounds. 

Effusion into the Pericardium. — As fluid accumu- 
lates, there is disappearance of the friction sound, as 
there was of friction fremitus, over the lower portion of 
the pericardium except when separation of the anterior 
surface of the heart from the pericardium is prevented 
by adhesions. At the base, and especially where the 
pericardium is reflected along the great vessels, the 
friction sounds may persist during the entire course. 
The cardiac sounds over the site of the normal apex are 
weak or inaudible, and are more distinctly heard toward 
the base of the heart over the sight of the visible 
impulse. The pulmonic second sound may be increased. 

The respiratory sounds are also modified. The 
respiratory murmur and vocal fremitus along the nor- 
mal site of the anterior border of the lung, especially on 
the left, are feeble or absent. Bronchial breathing and 
segophony may be heard in large effusions below the 
right nipple and behind at the angle of the left scapula. 

If the patient lies with face downward, or leans for- 
ward on the knee and elbow, the dullness and bronchial 
breathing in the back disappear. With absorption of 
the fluid, the friction sound may return, and there will 
be early disappearance of the respiratory signs. 

Cardiac sounds are heard in the normal site and with 



DISEASES OF THE PERICARDIUM. : > ,; 1 

normal intensity when myocardial changes have 
occurred. 

Adherent Pericardium. — The auscultatory signs are 
not distinctive, and depend on the condition of the sur- 
faces and the degree of change produced in the heart 
and at the valvular orifices. A rough pericardial fric- 
tion sound may be heard over different portions of the 
prsecordia, especially the base. The cardiac sounds 
may vary greatly. The first sound may have the 
valvular quality accentuated or may be doubled; the 
second sound may he reduplicated and accentuated. 
Both sounds may be heard abnormally clear behind. 
Endocardial murmurs, due to dilatation of the cavities 
may be present. 

Differential Diagnosis. — The distinctive features of 
acute, dry, fibrinous pericarditis are friction fremitus 
and friction sound of marked superficial, rubbing 
quality, with no fixed point of maximum intensity. The 
sound does not coincide with the areas of the normal 
valve sounds nor with the areas of endocardial mur- 
murs, and it is not transmitted beyond the prsecordia. 
Its rhythm is not accurately synchronous with the 
periods of the cardiac sounds, but has a double, to-and- 
f ro character. The intensity of the sound varies during 
the respiratory movements, and is increased by pressure 
over the praecordia, and is loudest when the patient is 
erect or bending forward. There is no evidence of 
cardiac enlargement. 

Acute Endocarditis and Chronic Valvular Disease. — 
The thrill present in endocardial diseases is localized at 
the apex (mitral obstruction) or at the base (aortic 
stenosis or regurgitation). It has a definite relation to 
the rhythm of the cardiac sounds, and does not give the 
impression of being superficial. The endocardial mur- 
murs have a definite area of maximum intensity and 
area of diffusion. Murmurs made at certain valves are 
heard beyond the prsecordia. The intensity of the 
murmur is not altered by pressure. Systolic murmurs 



362 THE CIRCULATORY SYSTEM. 

are loudest in the recumbent posture and fainter in the 
erect In chronic valvular disease, hypertrophy and 

dilatation of the hearl arc present. 

Pleuritic Fr/clion and Pleuro-pericardial Friction 

Sounds. — Friction sounds made in the pleura by the 
movement of the heart may simulate those of pericar- 
ditis. They are distinguished by the effect of respira- 
tion on the intensity and quality of ihe sound. On deep 
inspiration, the sound is intensified. When the patient 
takes a full breath and holds it, the sound disappears. 

Effusion into the Pericardium. — The distinctive 
features of effusion into the pericardium are that the 
visible cardiac impulse is raised ; the lower portion of 
the praecordia is fuller than normal; the intercostal 
spaces are wider and smoothed out, or even bulging, 
according to the extent of the effusion, and pulsations 
may be noted above the fourth rib. The percussion 
area of cardiac flatness is increased, and extends to the 
left beyond the normal site of the apex beat. To the 
right there is at first dullness in the fifth interspace, 
with gradual extension to the right of the sternum; the 
area of relative deep-seated cardiac dullness is dimin- 
ished, with a sharp line of demarcation between pul- 
monary resonance and cardiac flatness. The outline of 
the cardiac flatness becomes more pyramidal or pear- 
like. The sternal resonance is impaired from below 
upward in proportion to the distension of the peri- 
cardium. On auscultation, the cardiac sounds are 
feeble or absent over the apex, but are heard more 
clearly toward the base. Friction sounds over the base 
of the heart may be sometimes detected. Over the lung, 
the normal vocal fremitus and respiratory murmur are 
absent over the normal position of the anterior border. 
In extensive effusion areas of bronchial breathing are 
found in the right intermammary region in front, and at 
the angle of the left scapula behind. 

Dilatation and Hypertrophy of the Heart. — The 
visible, palpable apex beat is carried downward and to 



DISEASES OF THE PERICARDIUM. : > (;: > 

the left. Left ventricular hypertrophy causes forcible 
apex beat; in right ventricular hypertrophy the apex 
beat is diffused, and is seen and fell also in the epigas- 
trium. When dilatation predominates, the impulse is 
feeble and diffused, but felt at the lower portion of the 
prsecordia and in the epigastrium. 

Dullness does not extend beyond the apex beat to the 
left, nor flatness beyond the right of the sternum. The 
normal sternal resonance is but slightly impaired. 
There is relative greater increase in the area of dullness 
over that of flatness. 

The cardiac sounds are heard distinctly at the apex. 
When hypertrophy and dilatation are due to valvular 
lesions, the characteristic murmurs are present. 

Effusion into the Left Pleura. — In this condition dis- 
placement of the heart to the right gives elevation of the 
impulse and dullness or flatness to the right of the 
sternum. But the flatness on the left side extends 
beyond the prsecordia, and has its highest point in the 
axillary line, and is noted behind. Bronchial breath- 
ing, when present, is above the level of the fluid, but not 
at the angle of the scapula. 

Adherent Pericardium. — The characteristic feat- 
ures of adherent pericardium are flatness of the chest 
over the lower portion of the pra?cordia, with systolic 
retraction over the apex or other portions of the pra?cor- 
dia, according to the seat of adhesion, associated with 
diastolic rebound, and at times diastolic collapse of the 
veins. Rough, creaking pericardial friction sounds 
may be present. 

There are no pathognomonic signs of this condition, 
and diagnosis rests on the relation of the physical signs 
to each other. 

Cardiac Hypertrophy and Dilatation. — Systolic 
retraction over the apex may be present in massive 
cardiac hypertrophy with adhesions between the peri- 
cardial sacs. It is distinguished from adherent peri- 



364: THE CIRCULA TOR Y SYSTEM, 

carditis by the history of the case, and the presence of 
valvular lesions causing the hypertrophy. 

Pneumo-pericardium. 

Gas in the pericardium may be due to the decomposi- 
tion of the fluid contents or to perforation of the peri- 
cardium, which may be traumatic or may be due to 
ulceration from air-containing spaces. 

Physical Signs. Inspection. — Distension of the peri- 
cardium causes bulging over the prsecordia. The apex 
beat is weak or absent, and is most marked when the 
patient bends forward. 

Palpation. — Emphysematous crepitations may be 
present. Succussion splash may be felt with movement 
of the heart when air and fluid are present. 

Percussion. — The percussion sounds are most dis- 
tinctive. Over the pericardium there is a tympanitic 
percussion note, frequently with a ringing, metallic 
quality. Cracked-pot resonance may be present on 
forcible percussion when there is free opening. The 
percussion note over the praecordia varies with the 
posture of the patient. In the recumbent posture the 
entire praecordia is resonant. When the patient stoops 
forward, bringing the heart against the chest wall, a 
small zone of dullness may be detected. When fluid and 
air are in the pericardium, flatness may be present over 
the lower portion of the pericardium and tympanitic 
resonance above. The line of flatness changes with the 
position of the patient. 

Auscultation. — The character of the sounds vary 
according to the presence of air alone or of air and fluid 
in the pericardium. With air alone, or if there is but 
little fluid, the heart sounds have a loud, ringing, metallic 
quality. When the cardiac action produces movement 
of the fluid, metallic splashing or churning (water 
wheel) sounds are present. Endocardial murmurs, 
when present, are intensified by reverberation in the 
pericardium. 



CHAPTER XIV. 



DIAGNOSIS OF DISEASES OF THE BLOOD-VESSELS. 



ANEURISM OF THE AORTA. 

Dilatation of the aorta occurs in two forms: (1) 
Fusiform or cylindrical. In this form, at the seat of 
the dilatation, there is increase of the lumen of the 
artery in all directions without the occurrence of pouch- 
ing at any point, and unattended by the formation of 
any tumor or by pressure symptoms, even when the other 
physical signs of dilatation are very marked. To this 
form belong those general dilatations of the aorta and 
of the arteries given off from the arch, which may be due 
to changes primarily in the blood-vessels (aortitis, 
atheroma, etc.) or secondary to regurgitation at the 
aortic orifice. This form persists for a long time in a 
stationary condition, and beyond pulsation over the 
course of the artery, and the thrill and the murmur due 
to the enlarged lumen of the tube gives rise to no 
secondary symptoms. 

Acute dilatation of the blood-vessel frequently occurs 
in inflammatory conditions of the aorta. It may dis- 
appear under rest and treatment, or may remain as a 
permanent dilatation. 

(2) Sacciform or circumscribed form. This is due 
to dilatation involving a part only of the circumference 
of the wall of the artery, with the formation of a circum- 
scribed tumor whose cavity is connected with the lumen 
of the artery by an opening of varying size, but the 



3 G THE CIRCVLA TOR Y SYSTEM. 

diameter of the opening is smaller than that of the 
aneurismal sac. 

The aneurismal tumor, filled with coagulated or fluid 
blood, produces physical signs and symptoms which are 
in part due to the tumor itself and in part dependent 
upon its pressure upon the bony thorax, the heart, 
oesophagus, trachea, bronchi, lungs and mediastinal 
structures. The signs and symptoms of aneurism vary 
according to the size and situation of the tumor and the 
direction of its pressure. 



Table of Peessuee Signs in Aneurism. (Sanson.) 

( Local pain. 
Pressure of the bony thorax causes -j Local oedema (pulsation). 

( Absorption of tissue. 



Pressure on nerve causes . 



Pressure on blood-vessel causes 



Pressure on air tubes causes . 



Paralysis 



Unequal pupils, pa- 
ralysis of vocal 
cords. Hemiple- 
[ gia or paraplegia. 



L Asthmatic dyspnoea. 

f Inequality of pulses. 

f Local oedemas. 

Obstruction of -j Enlarged c o 1 - 

veins. ( lateral veins. 

Paroxysmal 

dyspnoea. 
Tracheal signs -> Brassy cough. 
Bilateral 

stridor. 



"Also paroxys- 
mal dyspiKea 
and cough. 

Unilateral 

stridor. 

Filling or con- 
solidation of 
luno; behind. 



Bronchial sigus^ 



Pressure on lung causes . . 
Pressure on oesophagus causes 



-{ Consolidation and displacement. 
-j Dysphagia. 



DISEASES OF THE BLOOD-VESSELS, :> > <; ^ 

Physical Signs, [nspection. /. Ascending Portion 
of the Arch. — Bulging of the thorax and pulsating 
tumor are present to the right of the sternum in the 
second and third intercostal spaces, except when the 

aneurism projects upward and inward from the lesser 
curvature. The apex beat of the heart may be in the 
normal position or be displaced downward. Pressure 
upon the superior vena cava causes distension of the 
superficial veins of the chest and localized cyanosis or 
oedema of the right side of the face or of the upper 
extremities. Pressure upon the sympathetic nerve 
causes contraction of the right pupil. Pressure upon 
the right or left bronchus causes diminished expansion 
of the corresponding side of the chest. 

2. Transverse Portion of the Aorta. — Bulging of the 
upper portion of the sternum, with diffuse pulsation 
most marked in the epigastric notch and in the arteries 
of the neck. Pulsating tumor is present when erosion of 
the ribs or sternum occurs. (Figs. 68 and 69.) Trachea 
displaced backward or laterally. Apex beat is gener- 
ally in normal position. Pressure upon left bronchus 
causes restricted motion of the left side. Pressure on 
the sympathetic nerve causes contraction of the pupil on 
the affected side. 

S. Descending Portion of the Arch and Upper Por- 
tion of the Descending Aorta. — When the sac develops 
on the anterior surface, there is bulging of the inter- 
costal spaces to the left of the sternum. The apex beat 
is displaced to the right, and two areas of pulsation are 
seen. When it develops on the posterior surface, there 
is absorption of the ribs and vertebrae, with pulsations in 
the interscapular space. 

Jf. Descending Aorta, Inferior Position. — Enlarge- 
ment of the lower portion of the chest, displacement of 
the heart upward and to the right, diffuse pulsations in 
the epigastrium and toward the left. Loss of respira- 
tory motion over the lower ribs. 

5. Abdominal Aorta. — Pulsating 1 tumor in the 



3G8 



THE CIRCULATORY SYSTEM. 



abdomen, frequently causing pulsations also over the 
hepatic area. 

Palpation. — By palpation the dilating or expansile 
impulse is felt over the aneurism, and associated with a 
well-marked diastolic shock, due to recoil of the blood 
upon the aortic valves. In a certain number of cases 
a well-marked thrill may also be detected. The force 

Fig. 68. 




Aneurism of aorta, bulging- of sternum and pulsating tumor. 



of the aneurismal pulsation should nearly equal that 
of the heart at the apex (Balfour). The location of the 
apex beat and the occurrence of confirmatory signs will 
vary according to the site of the tumor. 

1. Ascending Portion of the Arch. — Aneurism of 
this portion of the aorta is attended by a well-marked 



DISEASES OF THE BLOOD-VESSELS. 



3G9 



dilating impulse, accompanied with thrill, followed by 
diastolic shock. The apex beal is displaced downward 
and to the left, and usually increased in force. 

When the aneurism involves the innominate artery, 
the right radial pulse is usually smaller and slightly 
delayed. 

2. Transverse Portion of the A rch. — Over the sternal 
region the impulse is usually heaving in character, 

Fig. 69. 




'Aneurism of aorta, bulging of sternum and pulsating tumor. 

unless absorption and perforation have occurred. 
Fingers introduced into the episternal notch may detect 
the dilatation of the aorta, expansile pulsation and thrill. 
The radial pulse generally shows marked difference in 
character. Tracheal tugging is almost diagnostic of 
aneurism of this portion of the aorta. Pressure upon 
the oesophagus causes dysphagia. 
24 



370 THE CIRCULATORY SYSTEM. 

3. Descending Portion of the Arch and Upper Por- 
tion of the Descending Aorta. — When the aneurism 
develops forward, the apex beat is displaced toward the 
right, and may be found to the right of the sternum; 
while to the left of the sternum the aneurismal pulsation 
may be detected in the region of the normal apex. The 
aneurismal pulsation is slightly later than that of the 
apex. When it develops posteriorly, the apex may be 
displaced to the right or left, according to the direction 
of the tumor. Impulse may be felt in the interscapular 
space. 

J+. Descending Aorta, Inferior Portion. — The apex 
is elevated. There is diffuse pulsation over the lower 
portion of the thorax. 

5. Abdominal Aorta. — As the artery can be grasped 
through the abdominal wall, the dilating character of the 
pulsation is easily detected. 

Percussion. — There is diminished resonance or flat- 
ness over the site of the tumor. At times percussion 
detects the presence of aneurism when inspection and 
palpation are negative. When the sac projects close to 
the surface, its size may be definitely determined. 

1. Ascending Portion of the Arch. — Aneurism pro- 
jecting forward and to the right gives well-marked 
dullness in the second and third interspaces. 

2. Transverse Portion of the Arch. — Aneurism 
pressing upon the sternum causes dullness over the 
npper portion of the sternum, w x ith increased sense of 
resistance. When developing posteriorly or backward, 
increased dullness in the interscapular region may be 
detected. 

3. Descending Portion of the Arch and Upper Por- 
tion of the Descending Aorta. — Displacement of the 
heart causes percussion dullness over an abnormal site. 
Unless the aneurism projects close to the surface, it 
may be undetected by percussion. Posteriorly, increase 
in the percussion dullness may be made out in the left 



DISEASES OF THE BLOOD-VESSELS. : >T L 

interscapular space from the third to the sixth dorsal 
vertebrae. 

4. Descending Aortdj Inferior Portion. — The normal 
precordial flatness or dullness are extended to the left 
and over the lower portion of the thorax. 

5. Abdominal Aorta. — Dullness over site of tumor. 
Auscultation. — The signs detected by auscultation 

are not as distinctive as those noted by inspection, palpa- 
tion and percussion. Frequently over the aneurism 
the first and second sounds of the heart are heard with 
abnormal clearness, and are at times the only signs 
detected. One or both of the cardiac sounds may be 
replaced by a murmur or bruit, which varies widely in 
quality. A systolic bruit is most frequently present, 
and may be made in (a) the aneurismal sac, and gener- 
ally disappears when the contents become solid by 
coagulation ; ( b) in the dilated artery ; (c) in a portion 
of the aorta partially compressed by the tumor. A 
systolic murmur may be heard over the prcecordia 
(Drummond's sign), or detected when the chest piece 
of the stethoscope is introduced into the mouth and the 
lips closed on it (Sanson's sign). Corresponding to the 
diastolic shock felt on palpation, an intense, low-pitched, 
second sound may be heard over the aorta. When 
heard behind in the interscapular space, it is especially 
significant of dilatation of the aorta. A diastolic mur- 
mur is heard when incompetency of the aortic valve is 
present, and replaces the diastolic shock and sound. 
The respiratory sounds will be altered according to the 
site of the aneurism and the pressure on the trachea and 
bronchi, or displacement of the lung. 

1. Ascending Aorta. — Usually, the systolic and 
diastolic cardiac sounds are either intensified or replaced 
by murmurs. The most frequent combination is a well- 
marked systolic bruit, and a short, sharp diastolic shock 
or sound heard over the second intercostal space to the 
right of the sternum and behind in the interscapular 
region. Pressure on the right or left bronchus gives 



372 THE CIRCULATORY SYSTEM. 

rhonchi, tubular breathing (pressure type) and feeble 
vesicular murmur over the corresponding side of the 
chest. 

2. Transverse Portion of the Arch. — Cardiac sounds 
and murmurs are similar to those heard when the ascend- 
ing portion is involved. Pressure on the trachea caused 
harsh stridor to replace the normal respiratory sounds 
over both lungs. Pressure limited to the left bronchus 
gives tubular breathing at point of pressure and feeble 
vesicular murmur over the left side of the thorax. 

3. Descending Portion of the Arch and Upper Por- 
tion of Descending Aorta. — Usually distinctive changes 
in the cardiac sounds and murmurs are not present, and 
the diagnosis is made from evidences of pressure on the 
left bronchus and lung and from the displacement of the 
heart. Narrowing of the left bronchus causes stridor 
and diminished breathing below the affected portion. 
Occlusion of the bronchus and collapse of the lung are 
attended with absence of respiratory murmur and feeble 
vocal resonance. 

Jf. The Descending Aorta, Inferior Portion. — The 
auscultatory signs are very slight. Pressure of the 
tumor does not produce stridor, but may cause over the 
lower portion of the chest, occupied by compressed lung, 
bronchial breathing and increased vocal fremitus. 

5. Abdominal Aorta. — Usually over the site of the 
pulsation a well-marked systolic bruit is present. The 
systolic murmur over the aorta is not pathognomonic of 
aneurism, as it may occur when the aorta is relaxed, or 
displaced by anterior curvature of the spine, or slightly 
narrowed by the pressure of the stethoscope. 

Differential Diagnosis. — The distinctive signs of 
thoracic aneurism are the presence of visible pulsations, 
with or without bulging of the chest wall, and tumor. 
Over the tumor, when present, the pulsations are expan- 
sile, and frequently accompanied by systolic thrill and 
diastolic shock. The force of the pulsation felt should 
nearly equal that felt over the apex beat. The apex 



DISEASES OF THE BLOOD-VESSELS. old 

beat and area of cardiac dullness mnv be normal or dis- 
placed. Over the site 4 of the aneurism, when it reaches 
the surface, there may be flatness, surrounded by an 
area of relative dullness. When deep seated, diminu- 
tion of resonance only over that portion of the chest may 
be noted. Auscultation may reveal increased cardiac 
sounds, with diastolic shock or bruits replacing the 
normal sounds. In addition to the above, pressure 
signs will be present, varying in character according to 
the location of the aneurism. 

Mediastinal Tumors. — Mediastinal tumors have 
many physical signs in common with thoracic aneurism, 
especially those referable to pressure. The chief dis- 
tinguishing points are that mediastinal tumors, while 
producing bulging of the chest, are not attended with 
erosion of the bony thorax. The pulsations, when pres- 
ent, are not expansile, but convey the impression of a 
non-expansile force being transmitted. Over the site 
of pulsation, thrill and diastolic shock are not present. 
Pressure upon the large interthoracic veins produces 
more marked superficial venous disturbance. 

Glands in the clavicular and interclavicular and 
axillary regions are involved when the tumor is 
malignant. Over the site of bulging there is increased 
firmness of the bony thorax to pressure. 

The superficial area of flatness is very much greater 
than that over which pulsations are felt. Diminution of 
sternal resonance is especialy marked. Over the site of 
dullness, increased resistance and loss of normal thoracic 
elasticity are noticeable. 

Over the site of dullness and pulsation, distinctive 
cardio-vascular sounds are absent. Over the lung, 
pressure symptoms are more marked and uniform, and 
apt to be attended by secondary structural changes, due 
to extension of the growth from the mediastinal. 



<°> V4 THE CIECULA TOR Y SYSTEM. 

ARTERIOSCLEROSIS OR ARTERIO-CAPILLARY 
FIBROSIS. 

Tins condition causes increased peripheral resistance, 
with heightened arterial tension. 

The effects of arterio-sclerosis can be divided into 
three stages. First stage — In proportion to the inter- 
ference with the flow of blood through the capillaries and 
arteries, there is a corresponding hypertrophy of the left 
ventricle, which compensates for the lesion as long as the 
left ventricle is able to empty its contents into the aorta. 
The second stage or failure of compensation. — When 
the muscular power of the heart is insufficient to over- 
come the resistance in the aorta, dilatation of the ven- 
tricle occurs, with insufficiency of the mitral valves 
(mitral regurgitation), and the subsequent changes in 
the pulmonary circulation, and compensating hyper- 
trophy of the right heart. Subsequently (third stage) 
failure of the right ventricle to overcome interference 
with the pulmonary circulation may induce dilatation 
of the right ventricle, tricuspid regurgitation and inter- 
ference with venous return. 

Physical Signs. — The cardiac changes of arterio- 
sclerosis are identical with those that occur when the 
interference is due to obstruction at the aortic orifice. 
In arterio-sclerosis the obstruction is simply transferred 
from the area of the aortic valves to a more distant point 
in the arterial system. (See Aortic Stenosis, page 320.) 

The superficial blood-vessels are lengthened, promi- 
nent and tortuous, and the pulsations are visible. On 
palpation the artery is hard and incompressible, and 
even when the pulsations are obliterated can be felt 
beyond the point of compression as a hard, rounded cord. 
On auscultation, the aortic second sound differs from 
that of aortic stenosis, in that it is accentuated and ring- 
ing in quality. With failure of compensation at the 
left ventricle or regurgitation at the mitral orifice, the 
aortic second sound becomes indistinct. 



PART IV. 
THE ABDOMINAL ORGANS. 



CHAP TEE XV. 

INSPECTION. 

Inspection of the abdomen includes consideration of 
the shape and size of the abdomen, the changes in the 
skin, the condition of the blood-vessels, both arterial and 
venous, and the movements, both respiratory and visceral. 
The examination should be made with the patient in 
both the erect and recumbent postures when possible, 
although usually it is made in the recumbent position 
only. In the standing posture the shape of the abdomen 
and the support given the abdominal viscera by the 
parieties are most clearly seen, and in enteroptosis this 
method of examination is especially valuable. Exami- 
nation in the recumbent posture demands that the body 
shall be exposed from just below the mammary glands 
as far as the pubes, so as to compare the lower portion 
of the thorax with the abdomen. The patient should 
lie perfectly straight on the back, the head and trunk 
slightly elevated, so as to relax the abdominal muscles. 
The abdomen should be well illuminated, and the 
examiner should view it from all sides, so as to note any 
inequalities of surface and shadows caused by move- 
ments. 

The Normal Abdomen. — The contour of the abdomen 



376 THE ABDOMINAL ORGANS. 

should bear a definite relation to that of the thorax and 
genera] physique of the patient. In children and in the 
ad nit male past middle life the abdomen is relatively 
larger and rounder;, especially in the upper and middle 
zones. In males during early adult life there is gener- 
ally a depression in the epigastric region. In females, 
independent of the effects of tight lacing, there is 
more or less of a depression in the lower portion of the 
thorax and hypochondriac regions, with a lengthening of 
the waist line and a corresponding broadening of the 
lower portion of the abdomen. When compression of 
the thorax by corsets has occurred, this natural condition 
is made more marked. In those who have borne chil- 
dren, the lower portion of the abdomen is larger and the 
walls are flaccid. 

Examination of the Parietes. — The skin may show cer- 
tain discolorations (jaundice, pigmentation of Addison's 
disease and that secondary to pregnancy) or striae, the 
result of overdistension (pregnancy, ascites, obesity). 
It may be tense, dependent upon distension of the 
abdomen, or lax, secondary to overdistension from preg- 
nancy, ascites, tumors, and in wasting diseases. 

The blood-vessels may be more prominent than nor- 
mal, especially the veins, when the superficial ones are 
enlarged on account of compensatory changes due to 
obstruction of return circulation, either portal or 
general. 

The movements of the abdomen are (a) respiratory. 
These in the adult male and in children are especially 
marked. With inspiration the abdomen becomes promi- 
nent, especially in the upper zone. In females this is 
less marked, on account of the breathing being largely 
costal. "With, deep respiration the movements are more 
pronounced in both sexes. Increased respiratory move- 
ment occurs in diseases that interfere with expansion of 
the upper portion of the thorax. Diminished respira- 
tory movement occurs in all painful affections below the 
diaphragm, either involving the abdominal muscles or 



INSPECTION. :; < i 

the peritoneum, general or local, and especially thai por- 
tion covering the organs that are influenced by the 
descent of the diaphragm. 

(b) Visceral. — Peristalsis of the normal stomach is 
not noticed except when the abdominal walls are thin 
and relaxed. These movements may be noted when the 
stomach is distended and the peristalsis become 
exaggerated, especially when there is stenosis at the 
pylorus, with secondary hypertrophy of the walls. 

The movements of the stomach are seen as distinct 
waves, passing from left to right across the epigastric 
region to the costal margin on the right side. When 
more pronounced, they may cause protuberances or 
bosses of the abdominal walls, which pass slowly in the 
same direction. The latter conditions occur when the 
stomach is markedly dilated, and may at times be seen 
over a large portion of the abdomen. 

Movements of the small intestine may normally be 
seen when the abdominal walls are thin and. lax. Those 
of the large intestine are seen only in pathological con- 
ditions, dependent upon neuroses or stenosis, with over- 
distension of the gut above the site of obstruction. 
Those of the small intestine are vermicular, and are 
seen especially in the umbilical region. Those of the 
large intestine are especialy marked in the lumbar and 
epigastric regions, and the direction of the motion is 
contrary to that of the stomach, being from right to left. 

Enlargement of the Abdomen. — Enlargement of the 
abdomen may be (A) symmetrical, (B) localized. 
Symmetrical enlargement of the abdomen may be due 
to (1) increase of the abdominal walls (fat, oedema, 
(4c). (2) Distension of the peritoneal cavity by air 
(rare) or fluid (ascites). (3) Distension of the intes- 
tine with gas (meteorism). (4-) Massive tumor filling 
the abdominal cavity (uterus: pregnancy, fibroids; 
ovaries : distended bladder, etc. Although these condi- 
tions may cause uniform enlargement of the abdomen, 
certain peculiarities noted by inspection are aids in 



378 



THE ABDOMINAL ORGANS. 



differential diagnosis. Enlargement due to increase in 
the abdominal walls is associated with general obesity. 
The walls in the recumbent posture are more or less 
widened, and lack the dome-shaped appearance. In 
ascites the fluid collects in the most dependent portion of 
the abdomen, which enlarges laterally, and its shape 
changes as the patient is turned on the side or sits up. 

Fig. 70. 




Ascites due to cirrhosis of liver. 



(Figs. 70 and 71.) In accumulations of gas in the 
intestine, the abdomen is distended in all directions 
uniformly, and there is no change in shape with altered 
posture of the patient. In tumors the enlargement is 
not entire symmetrical. 

Local Abdominal Enlargement or Bulging. — Inspec- 



INSPECTION. 379 

tioD is very important in detecting local enlargements or 
bulgings. The abdomen should be viewed from all 
directions, in order to detect the shadows caused by 
unevenness of its surface. Local enlargements of the 
abdomen may be caused by enlargement of structures 
normally situated in that region or tumors springing 
from them, or the region may be invaded by organs dis- 
placed from adjacent areas. 

Epigastric Region. (1) Abdominal Walls. — Local 
contractions of the recti (phantom tumor) ; abcess of 
abdominal walls, lipomas. 

(2) Peritoneum. — Localized effusions into the lesser 
peritoneal cavity, tumors of the omentum. 

(3.) Stomach. — Distension from food or gas, or 
dilatation, with or without stenosis ; tumors of that 
portion of the stomach that is parietal (cancer, etc.). 

(Jf) Pancreas. — Cysts, cancer. 

(5) Aorta. — Aneurism of the aorta or its branches. 

(6) Liver. — Enlargements of the liver, displacement 
of the left lobe of the liver downwards, abscess, hydatid, 
gumma, cancer, etc. 

(7) Large Intestine. — Distension of transverse colon, 
tumor of colon. 

Umbilical Region. — Many of the conditions that were 
noted in the epigastrium may extend to this region also. 
• (1) Abdominal Wall. — Umbilical hernia, abscess, 
lipoma. 

(2) Peritoneum. — Encysted effusion into the peri- 
toneal cavity, tumors of the omentum. 

(3) Stomach. — Dilatation, tumors of the pylorus. 
(Jf) Aorta. — Pulsations of aorta due to aneurism or 

anterior curvature of the spine. 

(5) Enlarged Mesenteric or Retro-peritoneal Glands. 
— Tubercular, cancerous, etc. 

(6) Intestine. — Cancer of the intestine, especially the 
large intestine. 

(7 ) Movable liver; spleen, kidneys may project into 
this region. 



380 THE ABDOMINAL ORGANS, 

Hypogastric Region. — Distensions may be caused other- 
wise than by changes in the abdominal Avail and peri- 
toneum ; they arc dependent chiefly upon distended blad- 
der and enlarged uterus (pregnancy, tumors). 

Upper Right Lateral Region. — In the lateral region 
(including the hypochondrium and upper portion of the 
lumbar region to the level of the umbilicus) enlarge- 
ments due to changes in the abdominal walls and perito- 
neum are rare. 

(1) Liver. — Enlargements of liver (fatty liver, 
abscess, congestion, syphilis, hypertrophic cirrhosis, 
amyloid, displacement of the liver downward, leukaemia, 
hydatid, carcinoma). 

(2) Gall Bladder. — Distended gall bladder, gall 
stones, hydrops and cancer. 

(3) Ascending Colon. — Impaction of faeces, cancer. 
(Jf) Kidney. — Hydronephrosis, pyonephrosis, luemo- 

nephrosis, sarcoma, perinephritic abscess, cancer of 
suprarenals. 

Upper Leit Lateral Region. — (1) Stomach. — Dilated, 
distended, carcinoma of fundus. 

(2) Spleen. — Enlargements (congestion, primary or 
secondary, to obstructive disease of liver ; leukaemia, 
pseudo-leukaemia, malaria, movable or displaced spleen, 
abscess, carcinoma, hydatid. 

(3) Intestine. — Impaction of faeces in splenic flexure 
of colon. Enlargements of kidney. 

Lower Right Lateral Region. — (From the level of the 
umbilicus to the brim of the pelvis.) 

(1) Abdominal Wall. — Hernia, abscess of abdominal 
wall and psoas abscess burrowing forward. 

(2) Peritoneum. — Localized tumor secondary to dis- 
ease of appendix or intestine. 

(8) Intestine. — Tumors of appendix, impacted faeces, 
typhlitis, perityphlitis, intussception, cancer of caecum, 
or of ascending colon. 

(Jf) Kidney. — Displaced kidney. 

(5) Ovaries and Tubes. — Ovarian tumors, cysts of 



INSPECTION. : > s l 

the broad Ligament, pelvic abscess, tubal <>r extra-uterine 
pregnancy. 

Lower Leit Lateral Region. — Distension of the sigmoid 
flexure of the colon due to impaction of faeces, new 
growths in rectum, in addition to the same conditions 
may occur on the right side. 

Decrease in Size. — The abdomen may be decreased in 
size, due to contraction of the abdominal muscles, as 
occurs in the early stage of peritonitis and secondary to 
cerebral disturbance, especially basilar meningitis. In 
stenosis of the oesophagus or cardiac portion of the 
stomach, the empty condition of the stomach and intes- 
tines, with the emaciation, causes the abdomen to have a 
lax, shrunken appearance. 

Illumination of the Stomach. — The outline of the stom- 
ach may be seen by the use of Einhorn's gastro-diaphane. 
For this purpose the stomach is first washed out, and 
then filled with clear water, into which an electric bulb 
attached to a flexible wire is introduced. 



CHAPTER XVI. 

PALPATION. 

Method of Examination. — For satisfactory palpation 
of the abdomen, it is necessary for the patient to be in 
the recumbent posture, and the regions of the abdomen 
should be accessible from all sides. The head and 
shoulders should be elevated so as to relax the abdominal 
muscles, and the patient must be instructed to be as limp 
as possible, and not try to aid the examination by 
any voluntary motion. As the object of the examina- 
tion is to reach the abdominal organs, relaxation of the 
abdomen is a necessity. Very little is gained by having 
the patient draw up the legs, as there is a tendency to 
hold the abdominal muscles rigid in order to support 
them. When the patient is very nervous or apprehen- 
sive of the examination, it may be necessary to divert 
the attention by asking questions and seemingly to 
examine the tongue with the eye, while with the hands 
we are palpating the abdomen. The hands of the 
examiner should be warm, to avoid causing reflex con- 
traction of the abdominal muscles. 

At the beginning of the examination the palms of the 
hands should be placed lightly upon the abdomen and 
passed over it in all directions, so as to get a general 
idea of the condition of the walls, the degree of resist- 
ance. 

Patients who are very ticklish are frequently more 
disturbed by a light touch than by more forcible palpa- 
tion. The amount of pressure should be gradually 
increased, in order to determine whether any part 
of the abdomen is sensitive, as shown by pain and 



PALPATION. 383 

local muscular contraction. Whenever such areas are 
present, their examination should be left till the last. 

In general enlargement of the abdomen it is necessary 
to determine its resistance (gas, fluid or solid). 
When local enlargements are detected, we determine 
(1) their relation to the surface, (2) whether they are 
fixed or movable, the extent and direction of their 
mobility, and whether they move with respiration; (3) 
their shape and size, nature of their surface; (4) their 
relation to structures normally found in that region and 
to adjacent organs ; (5) the presence of frictions, thrills, 
and pulsations ; ( 6 ) whether they are sensitive or not. 

In order to gain more definite knowledge, it is often 
necessary after examination in the recumbent posture 
to put the patient in the lateral or in the knee-chest 
position. 

Abdominal Walls. — The condition of the abdominal 
walls affects the information obtained by palpation 
regarding the abdominal viscera. 

When the walls are thin and relaxed, they offer very 
little obstacle to palpation. Tension of the walls, due 
to muscular contraction, prevents satisfactory palpation, 
so that an anaesthetic may be required. Localized con- 
tractions, especially of the recti, due to ticklishness, pain 
or tenderness, frequently simulate tumors of the wall 
or underlying structures. 

Increase in thickness of the abdominal walls from 
fat renders palpation very difficult. 

Local enlargements and tumors of the abdominal wall 
may be due to (a) muscular contractions, (b) fatty 
tumors (lipomas), (c) abscess, (d) hernia. All these 
tumors give the impression of being superficial. They 
can be grasped by the hand, and their mobility is limited 
to that of the walls ; while tumors situated within the 
cavity do not have their mobility limited to the walls 
unless they adhere to the parietal peritoneum. 

Tumors due to muscular contraction vary in shape 
and size. Contraction of the recti causes a well-defined 



384 THE . I BDOMIN. 1 L ORG. ! NS. 

oblong mass, with the long axis corresponding to that of 

the muscles, while those of the oblique muscles are ill- 
defined. The characteristic feature of muscular tumors 
is their variable consistency; at one time they are hard 
and resistant, and as the muscle relaxes they become 
softer, smoother and finally disappear (phantom tumor). 
They may be painful when due to rheumatism or 
neuralgia, or attended with irritation of the parietal 
peritoneum. 

Lipomas are soft, yielding masses with fairly well- 
defined borders, and with greater or less mobility under 
the skin. Their firmness is increased when the surface 
over them is chilled by ether spray or the application 
of salt and ice. They are painless, and when grasped 
firmly and forced to the surface the skin over them 
shows depressions, indicative of the lobulated structure 
of the tumor. 

Abscesses are usually tense and elastic or fluctuating ; 
they are well defined unless surrounded by oedematous 
tissue, which gives a boggy feel and pits on pressure. 
Acute abscesses are red and painful, with local elevation 
of temperature. 

Hernias. The usual site of the hernial tumor is at 
the natural openings in the abdominal walls and the 
umbilicus, although they may occur at any part of the 
abdominal parietes. The mass gives an air-cushion 
feel, and becomes more tense as the intra-abdominal 
pressure is raised by deep breathing, coughing or con- 
traction of the abdominal muscles. They are not 
usually tender, and firm pressure may reduce the mass 
with sensation of gurgling. After reduction, the open- 
ing in the abdominal wall can be felt. Percussion over 
the mass gives a tympanitic note. 

Separation of the recti muscles leads to projection of 
the abdominal wall. The tumor is soft, yielding, with 
air-cushion feel and tympanitic note. 

Peritoneum. — Normally, the peritoneum presents no 
palpable phenomena. Acute general inflammation 



PALPATION. 385 

causes the abdomen to become extremely tender and 
resistant, on account of muscular contraction. Later 
paralysis of the intestine causes tympanites to be 
marked. Respiratory movements are diminished or 
absent. 

General peritonitis may be simulated by painful 
affections of the abdominal walls (rheumatism, neural- 
gia, lead colic, etc.) and tympanites, due to intestinal 
disease, or to hysterical conditions. In painful affec- 
tions of the abdominal wall, respirations are not dis- 
turbed to the same degree as in peritonitis. Pain ks 
more paroxysmal, and the constitutional symptoms are 
less severe. In hysterical conditions the physical signs 
may be identical. The diagnosis is made by considera- 
tion of all symptoms, especially others of an hysterical 
nature. 

Acute localized peritonitis is usually secondary to dis- 
ease of organs covered by the serous membrane, and will 
be considered with each organ. 

Diffuse thickening of the peritoneum secondary to 
acute or tubercular involvement gives an increased sense 
of resistance, and a more or less boggy feel. In local 
thickenings and ill-defined indurations there are felt 
nodular masses, more or less movable, simulating 
enlarged glands. They are frequently associated with 
thickening and retraction of the omentum (q. v.). 

Fluid tn the Peritoneal Cavity, Ascites. — Fluid 
causes a change in the normal feel of the abdomen, 
and abnormal sensations. The fluid collects in the 
most dependent portion of the sac, according to the 
posture of the patient; and as it increases the intes- 
tines are displaced, floating on its surface unless pre- 
vented by peritoneal adhesions or short mesentery. 
Over the fluid the normal air-cushion feel of the 
abdomen is replaced by increased resistance, as if the 
wall were thickened. This is especially noticeable in 
the flanks with the patient in the recumbent posture. 
Above the fluid the distension of the abdomen causes the 

25 



386 THE ABDOMINAL ORGANS. 

walls to be tense, otherwise the feel is normal. With 
change in posture of the patient, there is corresponding 
shifting of the fluid and intesl ines. 

Fluctuation. — When the palm of the hand is placed 

on one side of the abdomen near the level of the fluid, 
while on the opposite side a sharp percussion tap is made 
with the other hand, a wave-like motion in the fluid is 
felt as a distinct impulse, most distinct near the level of 
the fluid when the fluid is under tension and able to move 
freely. Under such conditions a light tap is sufficient 
to produce the phenomenon. When the abdominal wall 
is thick and the amount of fluid scanty, or if it is pre- 
vented from moving freely, the stroke must be stronger, 
and the impulse is feeble. It is often difficult to deter- 
mine whether the impulse felt has been transmitted by 
the fluid or by the abdominal wall. Transmission by 
the abdominal wall can be arrested if an assistant presses 
firmly with the ulnar edge of the hand in the median 
line. When the amount of fluid is small, fluctuation 
may be best detected by placing the patient on the side 
and placing a hand over the flank behind, between the 
lower ribs and the crest of the ilium, and tapping over 
the front of the abdomen. Fluctuation may be absent 
when the abdomen is overdistended and tension is very 
high, or when adhesion of the intestines or a short mesen- 
tery prevents the usual motion of the fluid. 

The abdomen in ascites is usually painless, unless the 
condition is secondary to peritonitis or complicated by 
it. Palpation of solid organs and tumors is prevented 
when the amount of fluid is large. By dipping (i. e., 
punching sharply with the tips of the fingers) over the 
organs sought for, the fluid is displaced, and the surface 
or edge of the solid organs can be felt. 

Fluid in the peritoneal cavity may be due (a) to 
inflammation of the peritoneum, simple, tubercular or 
cancerous; (b) interference with portal circulation 
(obstructive disease of the liver (q. v.), thrombosis of 
the portal vein, pressure on the portal vein from 



PALPATION. 387 

abdominal tumors, etc.) ; (c) interference with the 
genera] return circulation secondary to pulmonary and 
cardiac disease; (d) as a part of general dropsy (kidney 
disease, anaemic condition). 

The differential diagnosis of the cause is made by the 
physical signs of the primary lesion. Frequently the 
condition of the liver can only be determined after 
tapping. 

A localized collection of fluid may occur in any por- 
tion of the peritoneal sac. It is most common in the 
lesser peritoneal cavity, where it forms a tense, globular, 
cyst-like tumor in the epigastric region, not movable, 
and over which distinct fluctuation cannot be obtained. 
It is generally painless. At times it may transmit from 
the aorta pulsations which are not expansile. 

Air in the peritoneal cavity, due to perforative peri- 
tonitis, gives marked distension of the abdomen, with 
increased tension of its walls. The diagnosis from 
tympanites is made by percussion and auscultation. 

The Omentum is not palpable unless thickened by in- 
flammation or new growths. Deposits of fat in the 
omentum (peritoneal lipoma) give a thickened, elastic 
feel to the abdomen, with the impression of fluctuation. 
Thickening of the omentum may occur from chronic or 
tubercular peritonitis, and gives the sensation of 
increased superficial resistance over the upper zone of 
the abdomen, without any free border being detected. 
There may be tenderness in the acute and subacute 
stages, when more chronic there is no pain. The mass 
is not movable with respiration. Retraction of the 
thickened omentum may form a distinct tumor in the 
upper portion of the abdomen. The tumor may be felt 
as a transverse ridge with a distinct border below, which 
may simulate an enlarged left lobe of the liver, or it may 
be an irregular or ball-like mass. Cancer nodules may 
be diffused over the omentum, or new growths may form 
irregular masses similar to those in the stomach and 
liver. Tumors of the omentum do not move with 



388 THE ABDOMINAL ORGANS. 

respiration unless attached to the edge of the liver, in 
which case differential diagnosis is very difficult. They 
are differentiated from primary malignant growths of 
the stomach by being fixed, and more prominent when 
the stomach is full or inflated. 

Hydatid cysts of the omentum are rare. When 
unilocular, they give a sensation of superficial, globular 
tumors, and the hydatid thrill may be present. Multi- 
locular cysts, when small, may simulate the early stage 
of cancerous infiltration. 

Stomach. — Normally, the stomach cannot be detected 
by palpation, as only a small portion of the anterior sur- 
face and greater curvature is in contact with the 
abdominal wall. In extreme emaciation, during con- 
traction of the stomach, there is slight resistance. 
Normally, in most persons the upper portion of Jhe 
epigastrium is more sensitive to pressure than the rest 
of the abdomen. Increased tenderness over the gastric 
region occurs in acute and chronic catarrhal inflamma- 
tion of the stomach; in malignant disease, in ulcer (cir- 
cumscribed area) and whenever the peritoneal covering 
of the stomach is involved secondary to gastric disease. 

In dilated or displaced stomach the boundaries can- 
not be determined by palpation. The swelling noted 
by inspection gives a soft, yielding feel, except during 
contraction, when the sensation varies according to the 
cause of the dilatation. In atonic dilatation there is 
slight increase of resistance, and an even, wave-like 
motion from left to right can be detected. When dilata- 
tion is due to obstruction at the pyloris (cancer, ulcer, 
stenosis from adhesion, or displacement) there is hyper- 
trophy of the muscular coat, and the contractions of the 
stomach causes hard masses and irregular protuberances 
to be felt as the peristaltic wave passes across the 
abdomen. Over the region of the pyloris the con- 
traction is harder and longer, and almost always 
accompanied with sensations of gurgling or escape of 
gas. When the stomach relaxes a tumor may be felt. 



PALPATION, 389 

It is only exceptionally that the normal pylorus can be 
felt as a tumor. Splashing and succussion sounds 
(clapotage) can be obtained in a dilated stomach when 
it contains both gas and fluid. They are obtained by 
placing the tips of the fingers over the stomach and 
shaking it with quick movements, or by bimanual palpa- 
tion, one hand beneath the ribs behind and the other 
over the stomach in front. They are diagnostic of dila- 
tation only when taken in connection with other signs, 
as they can be obtained in the normal stomach, and in 
the colon when the contents are liquid. 

Tumors of the Stomach. — Tumors of the stomach 
can only be felt when situated in that portion which is 
in contact, normally or abnormally, with the abdominal 
walls. They may be due (1) to contracted stomach, 
(2) diffuse infiltration of the walls, with cancer; (3) 
local thickenings of different portions of the stomach 
wall by inflammatory products or new growths. 

The entire stomach may be so contracted as to form a 
tumor (a) in stenosis of the oesophagus or cardia, (b) by 
the prolonged use of concentrated diet, (c) by fibrous 
thickening of the stomach, with or without cancerous 
infiltration. In these conditions the stomach is usually a 
rigid mass, felt as a transverse ridge in the region of the 
normal stomach, and giving the same sensation as a 
thickened omentum. It is movable, and changes its 
position with deep breathing. 

Diffuse infiltration of the stomach wall may be later 
associated with contraction of the stomach and forma- 
tion of a tumor, as mentioned above, or the lumen of the 
viscus may be increased. In the latter condition the 
stomach is felt as a large, ill-defined mass, which, dur- 
ing contraction, becomes harder and has the more defi- 
nite contour of the stomach. It may occupy the normal 
gastric position, but is usually displaced downward, and 
the pylorus is felt somewhat to the left of the median 
line. 

Tumors or the Pyloric Region. — These may be 



390 THE ABDOMINAL ORGANS, 

due (1) to primary changes al the pylorus, as already 
mentioned, or to extension of cancerous growths from 
neighboring organs to this region. 

The characteristic features of primary tumor of the 
pylorus are (a) their location ; usually they are detected 
to the right of the median line, between the umbilicus 
and the ensiform cartilage. When stenosis is marked, 
dilatation and displacement of the stomach cause the 
tumor to be felt in the region of or below the umbilicus 
and to the left of the median line. (b) Mobility. 
When felt in the epigastric region, the tumor is movable 
in all directions, but more freely downward and to the 
left. When the pylorus is displaced below the 
umbilicus, the mobility is not so great, (c) The tumors 
vary in size, and are usually actually larger than palpa- 
tion would indicate, (d) Their consistency is hard: 
during peristalsis they become harder, and their contour 
more defined. (c) The detection of gurgling or escape 
of gas is an important diagnostic sign, especially when 
it occurs during peristalsis. 

Tumors of the pylorus, due to extension from neigh- 
boring organs, lack the characteristic mobility, and are 
usually associated with the physical signs of the 
primary growth. 

Pancreas. — The normal pancreas is not palpable, 
although claim has been made that in extremely thin 
persons and in those with enteroptosis it can be dis- 
tinctly felt. In diseased conditions the gland can only 
be detected when it is enlarged to a considerable degree. 
In acute or chronic pancreatitis it is not palpable, but 
in the epigastric region tenderness on firm pressure 
may be present with increased sense of resistance. 

Pancreatic enlargements are mostly due to cancer 
and cysts. Tumors due to tubercle, gumma, lymphoma 
and sarcoma are rare, and when present give most of the 
physical signs of cancer. - 

Caxcer of the Pancreas. — As this usually begins 
at the head of the gland, a tumor is felt in the epigas- 



PALPATION, 391 

triuin, midway between the xiphoid cartilage and the 
umbilicus, and a little to the right of the median 
line, close to the edge of the liver. Its form may be 
round or oblong, but the outline cannot be well 
defined. Its position is not influenced by respiratory 
movements. When it can be easily felt, it is generally 
fixed, <>r only slightly movable. Non-expansile pulsa- 
tions may be felt, due to its relation to the aorta. Com- 
pression by the tumor of the portal vein causes ascites; 
that of the vena cava causes (edema of the lower extremi- 
ties. The presence of a tumor in the region of the 
pancreas is not sufficient for diagnosis of cancer of that 
organ, as similar tumors may be caused by cancer of 
the pylorus, duodenum, colon, or liver. The associated 
signs of cancer of the pancreas are (1) early, intense 
and persistent jaundice; (2) dilatation of the gall blad- 
der, (3) enlargement of the liver, (I) fatty stools. 

Differential Diagnosis. — It is differentiated from tu- 
mor of the pylorus by being deeper seated and not mov- 
able, and that the stomach is not dilated and hypertro- 
phied. When the growth extends to the duodenum, 
stomach changes may be present. Tumors due to cancer 
of the lower edge of the liver, in the region of the pan- 
creas, move with respiration, and their relation to the 
edge of the liver can usually be determined. In primary 
cancer of the gall bladder the distended gall bladder is 
harder, while the liver is not enlarged. Enlargement of 
the retroperitoneal glands from any cause may give a 
tumor similar, as far as palpation is concerned, to can- 
cer of the pancreas. 

Cysts of the Pancreas. — When small, the tumor 
is felt to the left of the median line, toward the costal 
cartilage. It is globular, smooth, resistant and inelastic, 
and when deep seated gives a sensation of hardness. It 
is uninfluenced by respiratory movements, and on firm 
pressure may be slightly movable, both vertically and 
laterally. As the cyst enlarges, it is more in the median 
line, and displaces the stomach upward (rarely down- 



392 THE A B DO MIN A I ORG A XS. 

Avard). The transverse colon either overlies it or is 
pushed downward. It may attain to such a size as to 
fill the entire abdominal cavity, with compression of the 
bile ducts (jaundice), of the portal veins (ascites) and 
of the vena cava (oedema of the lower extremities). 
Pulsations over the tumor are frequently very pro- 
nounced, and, although they are transmitted from the 
aorta, may give a slight expansile sensation, and on 
auscultation often a bruit. Examination of the patient 
on the hands and knees removes these features, sug- 
gestive of abdominal aneurism. 

Differential Diagnosis. — Cysts of the pancreas cannot 
by physical signs be differentiated from effusion or 
hemorrhage into the lesser cavity of the peritoneum. 
Hydatid cysts of the liver, spleen or peritoneum may 
closely resemble cysts of the pancreas. They are some- 
what more movable and elastic, and frequently give 
fluctuation or hydatid thrill. Aspiration and examina- 
tion of the fluid chemically, showing it to be non- 
albuminous, and microscopical evidence of booklets 
determines their nature. Ovarian cyst may give similar 
signs on external palpation. Vaginal (bimanual) 
examination, however, shows its relation to the pelvic 
organs. 

In hydronephrosis the most prominent portion of the 
abdomen is usually situated to the right or left of the 
median line. The lower portion of the tumor extends to 
the brim of the pelvis. It is oblong, and the colon 
usually crosses its long axis toward its inner side and 
not transversely, as in pancreatic cysts. 

Liver. — Normally, with abdominal walls of ordinary 
thickness, the liver cannot be felt at the lower border 
of the ribs, except where the left lobe crosses the epi- 
gastrium. In persons with very lax walls, and espe- 
cially in women who have borne children, the liver may 
be felt in the right mammary line at or a little below the 
free border of the ribs. In children the relatively large 
size of the liver renders it more palpable. 



PALPATION. 393 

In palpation of the liver attention is paid to the fol- 
lowing: (1) Position of the lower margin and the 
degree to which it extends below tho free border of the 
ribs, and in the epigastric region. (2) Its consistency. 
(3) The condition of its surface, whether even or un- 
even. (4) Its edge, whether sharp, rounded or irregu- 
lar.- (5) Presence of pain or tenderness. (6) To what 
extent the change in the liver has involved other 
abdominal organs, especially the occurrence of jaundice, 
ascites and enlargement of the spleen. The diagnosis 
of the nature of the changes occurring in the liver 
depends largely upon the relative preponderance of 
these physical signs. 

The edge of the liver may be felt below its normal 
area, on account (A) of displacement without increased 
size; (B) of enlargement of the liver, either uniform or 
irregular. 

(A) Displacement of the liver may be due (1) to 
interthoracic conditions which depress the diaphragm, 
and with it the liver, as enlargement of the lungs from 
emphysema, asthma, pneumonia and tumors of the lung. 
Effusion into the right pleural cavity, pneumothorax, 
mediastinal growths, pericardial effusions, cardiac 
hypertrophy and dilatation, also effusions into the left 
pleural cavity, may cause localized displacement of the 
left lobe without any marked change in position of the 
right. (2) Sub-diaphragmatic conditions, as collections 
of fluid or pus between the diaphragm and liver. (3) 
Prolapsus of the liver from tight lacing, enteroptosis 
and deformities dependent upon rickets and spinal 
caries. 

The degree of displacement will depend upon the 
causal factors ; the shape, size, consistency and condition 
of edge and surface are usually normal unless enlarge- 
ment of the liver is a complication. In prolapsus of the 
liver, in addition to the ordinary respiratory movements, 
there is an independent mobility, due to the loose attach- 
ment of the organ. 



39-1 THE ABDOMINAL ORGANS. 

Differential diagnosis between displacement of the 
liver without enlargement and true enlargement of the 

viscus is made by the percussion outline. 

(B) I. Uniform Enlargements of the liver may be 
due (1) to circulatory changes which may be active, as 
occur in hot climates and in acute inflammatory condi- 
tions, and those dependent upon infectious diseases 
(malaria, typhoid and scarlet fevers, measles, yellow 
fever, small-pox, etc.) ; passive congestion dependent 
upon interference with circulation in the hepatic vein, 
due to cardiac or obstructive pulmonary diseases or 
pressure on the vena cava. (2) Blood diseases. 
Leukaemia, Hodgkin's disease, and pernicious anaemia. 
(3) Degenerations of the liver (fatty liver, amyloid 
liver, hypertrophic cirrhosis, diffuse syphilitic hepa- 
titis.). (4) Obstructive disease of the bile ducts (jaun- 
dice), either primary or secondary. 

II. Ieeegular Exlaegemexts or Tumoes of the 
Liver, due to cancer, hydatid and abcess, also 
syphilitic liver. These conditions may produce uniform 
enlargements. At times irregular enlargement of the 
liver may be due to prolongation of the lower portion of 
the organ and from the effects of pressure of tight lacing. 

(1) Congestions of the liver. In simple, active 
hyperemia of the liver the enlargement is slight. The 
lower border is felt just below the free edge of the ribs 
and slightly lower than normal in the epigastric region. 
The consistency is slightly increased, the surface is 
smooth and the edge well defined. In acute infectious 
diseases, especially typhoid fever in the early stage, the 
enlargement is identical with that of simple congestion, 
later changes in the liver cause it to become larger, 
softer, and the lower margin cannot be so readily 
felt. In other infectious diseases the liver shows vary- 
ing degrees of enlargement and consistency, but the 
normal shape remains. Tenderness is present when- 
ever the peritoneal covering is stretched or inflamed. 

In passive congestion of the liver the enlargement is 



PALPATION, 395 

in proportion to the amount of interference with the 
circulation. Secondary changes cause the organ to 
become harder; the surface is smooth, the n\^^ sharp 
and well defined. With secondary interference with 
the portal circulation, ascites occur. Jaundice occurs in 
secondary intestinal catarrh. Chronic congestion of the 
liver may also be due to malarial infection and residence 
in the tropics. 

(2) In leukaemia, Hodgkin's disease, pernicious 
anaemia and diabetes the enlargement of the liver is 
uniform, and varies with the severity of the disease. 
In leukaemia and Hodgkin's disease it is relatively less 
marked than the enlargement of the spleen and lym- 
phatic glands. The normal outline of the organ is 
retained ; it is harder than normal, and the edges are 
usually sharp and well defined; the surface is smooth. 

(3) In fatty liver the organ is uniformly enlarged 
and of normal shape. The enlargement may be very 
marked, and the lower edge reach almost to the crest of 
the ilium and below the umbilicus. The feel is soft and 
elastic; the surface is smooth, the edges round and well 
defined, and the outline can be easily made out by slight 
pressure. It is not tender to pressure, and is not 
attended with interference with portal circulation or 
enlarged spleen. 

Hypertrophic cirrhosis has many of the features of 
fatty liver. Its enlargement may be great, and it is 
harder than normal; the surface is smooth, and the 
edges sharper and well defined. With contraction of 
the connective tissue, there is diminution in size ; the 
liver becomes harder, the surface and edges irregular, 
but the nodules are small, assuming gradually the 
features of cirrhosis with enlargement. The organ is 
not tender to pressure unless associated with peri- 
hepatitis. 

In amyloid liver the enlargement is marked, but the 
liver has a hard, resistant feel, and the surface is smooth, 
with sharp, Avell-defined edges ; sometimes, however, they 



396 THE ABDOMINAL ORGANS. 

may be rounded. The edge of the liver cannot be 
moulded by firm pressure. Pain and tenderness are 
absent. Ascites occurs in the later stages. 

In diffuse syphilitic hepatitis the liver is larger and 
firmer than normal; the surface is smooth; the edges 
are sharp and well defined, similar in many respects to 
the condition noted in amyloid liver. 

Syphilis of the liver may cause the organ to be 
nodular when gummata are formed, and when contrac- 
tion of the fibrous tissue causes depressed areas with 
intervening nodules or bosses of hypertrophied liver tis- 
sue. The enlargement may be marked, extending nearly 
to the umbilicus. The consistency of the nodular masses 
varies according to the amount of connective tissue 
present. Gummata, when close to the surface, are more 
resistant than normal liver tissue. The enlargement of 
the liver is not rapid, and the nodules increase in size 
slowly. 

Cancer of the liver may cause enlargement to a vary- 
ing degree. Though it is usually massive, it may 
involve certain portions of the organ to a greater extent 
than others ; but the enlargements may be fairly uni- 
form. The consistency is not uniform, the cancerous 
masses being harder than other portions. The surface 
is irregular, and the irregularities may be felt as bosses 
or nodules of varying sizes. Frequently at the apex of 
a nodule a depression (umbilication) can be felt, and 
this is diagnostic of malignancy. These tumors may, 
however, be soft or semi-fluctuating. The edges are 
usually irregular, due to the projection of cancerous 
growths and to contraction of the liver substance. There 
is more or less tenderness on pressure over the prominent 
areas when the new growth involves the peritoneal coat. 
Ascites and jaundice occur in 50 per cent, of all cases. 

Abscess may develop in different portions of the 
liver, and cause irregular enlargement upward into 
the thorax or downward below the free border of 
the ribs and in the epigastric region, or outward through 



PALPATION. 397* 

the thoracic walls. When central, it may cause a more 
or less uniform enlargement of the organ. When it 
develops upward, the liver is displaced downward, but 
has the normal outline and characteristics. When the 
tumor develops from the lower portion of the liver, it is 
more or less globular; its surface is smooth, and fluctua- 
tions may he detected when the abscess is close to the 
surface. Pain and tenderness are variable. 

Hydatid cysts of the liver may cause enlargement 
similar in many respects to that of abscess. When the 
cyst is situated on the lower border of the organ, the 
mass is globular, soft and fluctuating, and at times the 
hydatid thrill may be detected. They are painless 
unless attended with localized peritonitis. 

(4) Obstructive disease of the bile ducts, primary 
and secondary, causes hepatic enlargement. The 
enlargement is usually slight, the consistency but little 
firmer than normal, the surface smooth and the edges 
well defined. Interference with portal circulation and 
enlargement of the spleen occur according to the nature 
of the cause (see Gall Bladder). 

Differential Diagnosis. — Differentiation by palpation 
of the uniform enlargements of the liver from each 
other and from displacements through thoracic or sub- 
diaphragmatic conditions has been described in consider- 
ing the different diseased conditions of the organs, and 
will be further discussed under percussion and ausculta- 
tion. 

The irregular enlargements may be simulated by 
other tumors occurring in organs adjacent to the liver. 
The most prominent of these are accumulations of 
feces about the hepatic flexure of the colon (see Intes- 
tine), cancer of stomach (see Stomach), right renal 
enlargement (see Kidney), puckered or indurated 
omentum (see Omentum), and tumors of the abdominal 
wall. Usually the differentiation is made not only by 
the signs obtained from palpation, but from those 
obtained by percussion and auscultation, together with 



308 THE ABDOMINAL 0&GAN8. 

the secondary effects of these tumors upon organs with 
which they are connected. 

The most important features of tumors of the liver 
are their mobility, their parietal situation and their 
well-defined relation to the edges of the liver, jaundice 
and ascites. Cancerous growths that involve the liver 
and neighboring organs late in the disease have no dis- 
tinctive features by which the origin of the growth can 
he determined, and the differential diagnosis is made 
from the history and the secondary effects. 

Gall Bladder. — When it is empty, the gall bladder can- 
not be felt, but when moderately distended it may be 
detected as an ill-defined mass at the edge of the right 
ninth costal cartilage, close to the outer edge of the 
rectus muscle, which corresponds to that point at the 
free border of the ribs where a line drawn from the 
right acromial! process to the umbilicus crosses it. 

Palpable enlargements of the gall bladder are due (1) 
to distension by (a) bile, (b) mucus (hydrops), (c) 
pus (empyemia) and (d) to gall stones which may be 
caused by inflammatory conditions or stenosis or obstruc- 
tion in the cystic or common ducts. (2) To new 
growths, malignant and benign. 

Enlargements of the gall bladder, from whatever 
cause, have certain features in common. The size 
varies greatly from a scarcely palpable tumor to one 
of large size ; usually, however, it is not larger than a 
good-sized pear. The degree of enlargement of the 
same tumor may vary from time to time. The tumor is 
smooth, rounded and gourd-like, the large end being the 
most dependent. When the tumor becomes very large, 
the lower portion becomes more globular in relation to 
the neck, which is thin. When the distension is due to 
gall stones, the tumor may have a nodular feel. 

The tumor has a double mobility, moving with the 
liver with respiration, and also being more or less 
freely movable in all directions about its point of attach- 
ment to the liver, the range of motion being one of the 





: LIVER.— LEUBE. 








EDGE 


OF LIVER. 


SURFACE 


OF LIVEB 


luck. 

Bounded. 


Nodular. 


Smooth. 


Nodular. 











Simple y liver. 


Cirrhosis (rarely 


Congestion. 


Cirrhosis. 


Atrophpestion. 


palpable). 


Fatty liver. 


Abseess. 


liver vloid. 


Abscess. 


J a u n (1 ice, ob- 


Syphilitic liver. 


Atroph 


Carcinoma. 


structive. 


Carcinoma. 


Syphili 


Syphilitic liver. 


Elephantiasis. 


Echinococcus. 


(atroi 


Tubercle bacilli. 


Amyloid. 




rare ) 






Leukaemia. 




Acute \ 










phy. 






Diabetes liver. 

Acute y el 1 o w 

atrophy. 





ENLARGEMENT OF THE SPLEEN. 



absent. 



Present. 



Amylcf moma 

Fatty 1">- liver - 

Adhesi 
phlfl 



Echinococcus unilocularis (rarely from stasis in the 
portal system). 

Congestion. 

Syphilitic liver. 

Cirrhosis (atrophic). 

Echinococcus multilocularis. 

Hypertrophic cirrhosis. 

Amyloid. 

(Also in acute yellow atrophy and abscess due to the 
general systemic infection.) 



yase increases in frequency or intensity as the column is read 



TABLE FOR DIAGNOSIS OP DISEASES OF THE LIVER. -LEU BE. 



SIZE OK LIVER. 




CONSIST 


BNCY OF LIVER. 




Diminished. 


Increased 


Soft to 
Fluctuating-. 


Firm, a little 

harder than 

normal. 


Hard. 


Smooth to Sharp. 


Simple atrophy. 


Liver abscess. 


Fatty liver. 


Simple atro- 


Engorged. 


Fatty liver, elas- 


Atrophic nutmeg- 


Diabetes liver. 


Abscess. 


phy. 


Cirrhosis. 


tic, thrill. 


liver. 


Congestion. 


Echinococcus 


Jaundice. 


Syphilitic liver. 


Jaundice, ob- 


Atrophic cirrhosis. 


Jaundice, ob- 


unilocularis. 


Hyperemia. 


Echinococcus 


structive. 


Syphilitic liver 


structive. 






multilocularis 


Hypertrophic cir- 
rhosis (some- 
times slightly 


(atrophic form, 


Fatty liver. 






(becoming soft). 


1 a. 








Amyloid. 


rounded). 


Acute yellow atro- 








Carcinoma. 




phy. 














Syphilitic liver. 






Hypertrophic cir- 


Simple atrophy. 




Leukaemia. 






rhosis. 






Hypertrophic cir- 












rhosis. 












Amyloid. 












Carcinoma. 












Echinococcus. 











EDGE OF LIVER. 



Thick, 
Rounded. 



Fatty live) 
< lonbestioi 



Cirrhosis (rarely 
palpable). 



Smooth. 


Nodular. 


Congestion. 


Cirrhosis. 


Fatty liver. 


Abscess. 


Jaundice, ob- 


Syphilitic liver. 


Elephantiasis. 


Carcinoma. 


Amyloid. 




Diabetes liver. 




Acute yellow 

































JAUNDICE. 




ASCITES. 






,o™.™. 


Absent. 


Bare. 


Frequent. 


Absent. 


Present. 


Pain Present. 




bsent. 


Present. 


Amyloid. 


(Only when the 


Abscess. 


Fatty liver. 


Carcinoma, 


Echinococcus 


Car 


inoma. 


Echinococcus m 


iloeularis (rare 


y ,•„„„ 8ta8j8 „. 


Fatty liver. 


biliary pas- 
sages are di- 
rectly involved 


Congestion. 


Elephantiasis 


Syphilis with 


multilocularis. 


Fat 


v liver. 


porta] system). 






Adhesive pyle- 


Cirrhosis. 


Jaundice, ob- 


contraction. 


Acute y e 1 1 o w 
atrophy. 




Congestion. 


. 




phlebitis. 


in the diseased 


Carcinoma, 


structive. 


Echinococcus 




Syphilitic liver. 








processes). 


Echinococcus 


multilocularis. 


Carcinoma. 




Cirrhosis (atroph 


c). 






Echinococcus. 


Echinococcus 
multilocularis 


unilocularis. 


Cirrhosis. 


Syphilitic liver. 




Feb coccus mu 


tilneularis. 






Syphilitic liver. 


Elephantiasis 

Jaundice, ob- 
structive. 


Abscess. 


Adhesive pyle- 
phlebitis. 

Amyloid. 

Congestion (con- 
stant in the late 
stages). 


Abscess. 






■ infection.) 


*■*" ' '"""• 



—In general, the diseases a 



rranged in the col in 



5 that the individual s 



each disease i 



PALPATION. 399 

diagnostic features of the tumor. Generally it can be 

carried up and caused to disappear beneath the liver, 
and can also be carried to the median line; but it is 
impossible to displace it downward toward the pelvis. 

Its relations to the liver are well denned; a sulcus can 
be usually detected between the enlarged gall bladder 
and the liver. Fluctuation cannot be detected, as the 
tumor is usually too tense. The tenderness varies. 
When due to obstruction from gall stones, pressure over 
the tumor may cause colicky pains. 

Malignant growths of the gall bladder are usually 
hard and more or less irregular. The size in this con- 
dition is not so great as in distension by its contents. 

Enlargement of the gall bladder may be associated 
with enlarged liver when obstruction of the common bile 
duct occurs from any cause, and jaundice will then be a 
marked and persistent symptom. When the obstruc- 
tion occurs in the cystic duct, jaundice, if present, is 
transient, and not intense. 

Differential Diagnosis. — Tumors of the gall bladder 
may be confounded with prolongations of the lower edge 
of the liver, with hydatids of the liver, with movable 
kidneys, tumors of the intestine and tumor of the 
pylorus of the stomach. 

(1) Abnormal prolongations of the lower border of 
the liver do not have free mobility, and their outline is 
usually continuous with the smooth, convex surface of 
the liver. Their size is permanent. 

(2) Hydatid tumor attached by a pedicle may simu- 
late an elongated gall bladder. It is more distinctly 
fluctuating, and frequently hydatid thrill can be 
detected. It is painless, and, while it is movable, has 
not the same range of mobility as has the gall bladder, 
and it is displaced more slowly. 

(3) Movable or floating kidney has many features in 
common with enlarged gall bladder. Both tumors are 
rounded and smooth, but that of the gall bladder is 
gourd-shaped, the narrow portion projecting toward the 



400 THE ABDOMINAL ORGANS. 

fissure of the liver, the enlarged lower end lying toward 
a point just below the umbilicus. The kidney retains 
its normal shape. The feel of the two is also some- 
what different. The gall bladder is usually firmer, and 
when filled with calculi may show an irregular outline. 
The gall bladder gives the impression of being super- 
ficial, and it is constantly felt when pressure is made 
over the front of the abdomen. Movable kidney, on the 
other hand, is variable in its situation, and it is not 
always detected in the same position by anterior palpa- 
tion. The two tumors differ in range of mobility. The 
gall bladder is influenced by respiration, and the kidney, 
when situated close to organs that move synchronously 
with the diaphragm, may also have a similar motion. 
The gall bladder moves around a fixed point, and can be 
pushed upward to either side and backward, but not 
downward into the pelvis ; and when displaced behind 
the liver towards the normal kidney-position it tends to 
return to its own normal position in front of the 
abdomen. The kidney moves readily to different loca- 
tions in the abdomen. It may be carried to the median 
line and beyond or downward into the pelvis, and 
upward and backward into the normal position, where it 
tends to remain until displaced by pressure over the loin 
or by posture. It slips underneath the examining fin- 
gers like a "greasy mass." 

When the large intestine is inflated, the gall bladder 
is pushed up and becomes more prominent. The mov- 
able kidney disappears behind the intestine, and cannot 
be felt. 

Tumors of the pyloric region of the stomach, while 
movable, do not have the same range of motion, being 
displaced farther to the left beyond the median line, 
with a more restricted mobility to the right. Associated 
conditions are usually sufficient for diagnosis. 

Spleen. — The spleen is deeply situated underneath the 
bony thorax posteriorly, and is normally not palpable, 
except when the abdominal walls are thin and lax and 



PALPATION. 401 

the spleen is slightly movable, and can be pushed for- 
ward so as to be brought close to the costal margin in the 
hvpochondrinm. Frequently, when the spleen is abnor- 
mally movable, turning the patient on the right side 
causes it to have an anterior position, and to be felt 
as a movable tumor. Deformity of the thorax, espe- 
cially when involving the spine, may cause the normal 
spleen to be palpable. 

Movable or wandering spleen gives, in addition to the 
tumor that is felt at the free margin of the ribs, a 
diminished sense of resistance on palpation over the 
normal area, and a more tympanitic percussion note. 

ENLARGEMENTS of the Spleen. — Conditions that 
increase the spleen in size cause it to develop anteriorly, 
and to be felt under the free border of the ribs. The 
enlargements may be uniform or irregular. 

Uniform enlargement occurs (a) in infectious and 
febrile diseases. In many of these the enlargement, is 
so slight as to be scarcely palpable. In typhoid fever, 
scarlet fever, small-pox, it is generally palpable, accord- 
ing to the severity of the disease. In erysipelas, sepsis 
and pyaemia, also in acute tuberculosis, the enlargement 
of the spleen may be sufficient to bring its free edge 
beyond the border of the ribs, (b) In interference with 
the portal circulation from primary disease of the liver 
(q. v.), or to cardiac or respiratory disease, (c) In 
chronic hypertrophy, due to amyloid disease, leukaemia, 
Hodgkin's disease, splenic ansemia, chronic malarial 
infection (ague cake), and occasionally in syphilis and 
tuberculosis. 

The irregular enlargements occur chiefly in hydatids, 
cancer and abscess. 

The characteristics of splenic tumor are: (1) They 
are superficial, and are not separated from the abdomi- 
nal walls by any of the abdominal contents. The upper 
portion disappears under the free border of the ribs, 
and cannot be defined. (2) They move with respira- 
tion, and have also a slight independent range of motion 
26 



402 THE ABDOMINAL ORGANS. 

upward and backward on firm pressure. They have 

passive mobility toward the median line and down- 
ward when the patient is turned on the right side and 
put in the knee-chest position. (3) The tumor in 
uniform enlargements retains the normal splenic con- 
tour, and when it extends any distance beyond the free 
border of the ribs the notch can be easily detected. (4) 
The surface of the tumor is smooth. (5) The consist- 
ency varies. In acute enlargements, due to infectious 
and septic diseases, it is soft and yielding ; in the more 
chronic enlargements it is hard and resistant. In the 
irregular enlargements of cancer, hard, nodular bosses 
may be felt on the surface. In hydatid cyst, when the 
tumor can be readily palpated, it is tense, elastic and 
rounded; fluctuation, however, can rarely be detected, 
but hydatid thrill may be obtained. 

(6) The edge of the spleen is usually well defined, 
and, with the notch, is one of the diagnostic features. 
' When the consistency of the spleen is soft, the edge is 
not so distinct as in some chronic enlargements, espe- 
cially malarial. 

The size of the spleen varies in different enlarge- 
ments. In the chronic enlargements of leukaemia, 
Hodgkin's disease and malaria the size is greatest. The 
spleen is rarely painful, except when the peritoneal 
covering is involved, as occurs in acute inflammation, 
infarction, syphilis and abcess. Posteriorly, the 
splenic enlargement does not extend to the median line, 
so that forcible palpation below the ribs in the flank 
may enable us to distinguish the edge between the edge 
of the tumor and the erector spina? muscles. 

Differential Diagnosis. — The acute enlargements of 
the spleen cannot be differentiated by palpation. When 
dependent upon engorgement, due to obstructed portal 
circulation, the enlargement is usually associated with 
changes in the liver and heart, and there is more or less 
ascites. 

Of the chronic enlargements, amyloid enlargement is 



PALPATION. 403 

rarely groat. It is usually associated with similar 
changes in the liver and kidney, due to prolonged sup- 
puration. In leukaemia the splenic enlargement is 
marked, and is attended with anaemia and changes in the 
superficial glands and liver. In ITodgkin's disease the 
splenic enlargement is relatively marked, as is also the 
enlargement of the lymph glands. In ague cake the 
enlargement closely resembles in size and consistency 
that of splenic leukaemia, and the differential diagnosis 
is made on the blood examination. 

Enlargement of the spleen in anaemia (splenic 
anaemia) occurs chiefly in children, and is not attended 
with blood changes of leukaemia or malarial infection. 

Splenic enlargement may be confounded with other 
tumors appearing in the left upper portion of the 
abdomen, the most important of which are fecal accumu- 
lations in the descending colon and sigmoid flexure. 
Faecal masses are distinguished by the absence of 
respiratory and passive motion, the rounded contour, 
absence of the notch and sharp edge, the peculiar feel, 
and the effect of treatment (purgatives). 

Cancer of the stomach, especially of the greater 
curvature, and the cardia may give an ill-defined tumor 
under the free border of the ribs. When the tumor 
becomes palpable in the epigastrium or below the ribs, 
the hard feel, associated with gastric symptoms, readily 
distinguish it. 

The differential diagnosis between tumors of the left 
kidney and spleen will be considered below. 

Kidneys. — The normal kidney cannot be detected by 
palpation, except in children and in persons who are 
thin and have very lax abdominal walls, when the lower 
edge can be felt on bimanual palpation just underneath 
the free border of the ribs, at the end of a deep inspira- 
tion. The kidneys may be palpable when they are 
abnormally movable or wandering, or enlarged. 

Movable kidneys are those which have a range of 
motion downward toward the pelvis, and which do 



401 THE Mi DOM I SAL DUG ASS. 

not extend laterally into other portions of the abdomen. 
In this condition, when the patient is standing and 
leaning forward, or at the end of deep inspiration 
when in the semi-recumbent posture, the kidney may 
be felt to glide under the hand into the pelvis, so 
that the upper border can be felt. On change of posi- 
tion or pressure from below, the kidney slips back into 
its normal position. The cause of movable kidney may 
be enteroptosis or emaciation in a person who has once 
been very stout. It is especially liable to occur in 
women who have borne children and with overstretched 
abdominal walls. Anterior curvature of the spine, 
involving the lower dorsal and lumbar vertebrae, fre- 
quently displaces the kidney forward, so that it is both 
seen and felt in the anterior portion of the abdomen. 

Wandering kidneys have a wider excursion, and may 
occupy any part of the abdomen, moving from place to 
place with ease, according to the posture of the patient 
and the direction of pressure. The kidney shape is 
retained, which enables one to recognize the organ ; the 
borders are rounded, and the hilus is frequently palpa- 
ble. On firm pressure pain of a sickening character is 
elicited, frequently radiating down toward the bladder. 

Enlargements of the Kidney. — Enlargements 
of the kidney are due to (1) malignant disease (sarcoma 
and carcinoma), (2) cystic degeneration, (3) hydatid, 
(4) hydro- and pyo-nephrosis, and (5) perinephritic 
abscess. 

Renal tumors are extremely difficult to diagnose, and 
are frequently confounded with those of other organs. 
Their most characteristic feature is their relation to 
the surface. When they reach the anterior portion 
of the abdomen, their most prominent part is at the 
umbilicus or just above it. They occupy the space 
between the crest of the ilium and the costal margin. 
Posteriorly, they fill the entire space between the lower 
border of the ribs and the pelvis, causing a smoothing 
out of the hollow of the loin, but rarely any prominence. 



PALPATION. 405 

Forcible palpation in this area gives a uniform resist- 
ance, extending to the spine. The mobility of the 
tumors is but slightly influenced by respiration, although 

when they are large and in contact with the diaphragm, 
a slight respiratory mobility may be detected, but it is 
never as marked as in tumors of the liver and spleen. 
The statements that kidney tumors are totally uninflu- 
enced by respiration frequently lead to error in 
diagnosis. 

The size of the tumors varies greatly, and also that of 
the same tumor from time to time. Tumors due to 
sarcoma, cystic degeneration and perinephritic abscess 
are stable in size, and may reach great dimensions, 
especially sarcoma in young subjects, almost filling the 
entire abdominal cavity. They rarely cause projec- 
tion of the lower ribs or fill the pelvis. Those due to 
hydro- and pyo-nephrosis are more variable in size, 
according to the degree of distension. 

The uniform enlargements preserve to a marked 
degree the kidney shape. Perinephritic abscesses, on 
the other hand, may be somewhat globular. 

The consistency of the tumor varies, being hard and 
dense in malignant disease and elastic in other forms, 
varying with the degree of tension. 

Fluctuation can rarely be detected. The relation of 
enlargement of the kidney to other structures is some- 
what characteristic. The large intestine usually over- 
lies the tumor, and can be detected by palpation and 
percussion. (Fig. 74.) The small intestine may also 
be between it and the abdominal wall. In exceptional 
cases the tumor may displace the colon downward and 
toward the median line on the right side, or carry the 
descending portion of the colon toward the median line 
so as not to be covered with it. This relation of the 
large and small intestines to the tumor overlying it dis- 
tinguishes it from splenic tumors (Fig. 73), which are 
always parietal and never have the gut between them and 
the abdominal wall, and, on the other hand, liver tumor, 



10T) THE ABDOMINAL O&GANS. 

which is usually parietal, but may occasionally have the 
small intestine between the abdominal wall and itself 
when the enlargement is irregular and is associated with 
ascites. 

Irregular Enlargements. — Irregular enlargement 
of the kidney by malignant disease or abscess may cause 
the tumor to lose its reniform shape, making it abnor- 
mally prominent in one direction ; and may also change 
the normal relation to the intestine. 

Differential Diagnosis. — Renal tumors are differen- 
tiated from splenic tumors by the rounded contour and 
the absence of the sharp, well-defined edge and notch ; 
also by the presence of intestine over the tumor (per- 
cussion). The renal tumors are less movable. The 
renal tumors, if they passed beneath the ribs, leave a 
palpable sulcus, due to their rounded border. Splenic 
tumors are in close contact with the anterior surface. 
Posteriorly, renal tumors occupy the entire space 
between the free border of ribs and crest of ilium, and 
the resistance is uniform. In splenic tumors an unoccu- 
pied area can be detected in the flank, which is also 
resonant on percussion. 

Hepatic tumors are also parietal at the costal margin, 
and the free edge of the tumor, with the sharp, well- 
defined margin, is transverse to the abdomen, following 
the normal slant of the liver. When renal tumors 
develop upward, so as to be in contact with the liver, a 
sulcus can usually be detected between the rounded edge 
of the tumor and the sharp, displaced edge of the liver. 

Ovarian tumors are parietal, and are surrounded with 
intestines, giving resonance on percussion. They grow 
upward from the pelvis, and reach the surface just 
below the umbilicus, while renal tumors generally 
develop from behind forward, and first reach the 
abdominal wall at or a little above the umbilicus. 

The massive ovarian tumors generally become cen- 
trally situated, while renal tumors remain unilateral. 
Ovarian tumors cause displacement of the uterus up- 



PALPATION. 407 

ward or downward. Renal tumors rarely involve the 
pelvis. 

Intestines. — The different portions of the intestine 
cannot be distinguished from each other by palpation. 
The small intestine normally is not palpable. It is 
possible to feel certain portions of the large intestine 
when the abdominal Avails are thin and relaxed. The 
sigmoid flexure of the colon can most frequently be 
detected, and occasionally the head of the caecum and 
ascending colon. The transverse portion cannot be 
made out. The appendix is only at times palpable, 
although the statement is frequently made that it is 
possible to feel it both by surface and bimanual palpa- 
tion, one finger being in the rectum or vagina. Dif- 
ferent portions of the intestinal canal may become 
palpable when distended with gas or the walls become 
thickened through muscular contraction or inflammatory 
products or new growths, or when the canal becomes 
filled with semi-fluid or solid contents. In simple disten- 
sion of the intestines, with relaxation of the intestinal 
walls, the entire abdomen has an air-cushion feel. When 
the distension is the result of chronic obstruction in any 
portion of the tract, the hypertrophied intestine may be 
more or less distinctly felt during peristalsis. 

Localized inflammatory thickening of the intestinal 
wall may occur at any point. It is rarely palpable in 
the small intestine, as it is usually associated with nar- 
rowing of the part and distension of the intestine 
immediately adjacent. 

Thickening of the caecum, appendix and ascending 
colon causes a tumor to be felt in the right iliac region. 
The appendix may be detected as a hard, cord-like mass, 
more or less freely movable under the finger. When 
acutely inflamed and associated with peritoneal involve- 
ment and rigidity of the muscles, the appendix cannot 
be distinguished as such, but an ill-defined tumefaction 
or a distinct tumor occupies the appendicular region, 
with a marked tenderness at a point midway between the 



40S THE ABDOMINAL ORGANS. 

anterior superior spine and the umbilicus ( McBurney's 

point). 

Involvement of the caecum, with extension of inflam- 
mation to surrounding parts (typhlitis), causes a 
similar tumor to be felt. Abscess formation (peri- 
typhlic abscess) in this region, due to inflammation of 
either appendix or caecum, gives a less resistant tumor, 
with a sensation of deep-seated fluctuation. 

Cancer of the head of the caecum and iliocsecal valve, 
producing stenosis, causes a tumor that is hard, resistant, 
and, unless the neoplasm has extended to surrounding 
structures, nodular and movable. 

The tumor of intussusception in this region is smooth, 
uniform, and not tender on pressure. It is also asso- 
ciated with distension of the intestine, and may not be 
palpable. Tympanites is marked. 

Fsecal impactions, occurring in the ascending colon, 
give an oblong tumor with a rounded contour, which 
may extend from the middle of Poupart's ligament to 
the under surface of the liver. The surface may be 
smooth, but it is usually more or less irregular or 
lumpy, and on firm pressure an indentation may be 
caused. When the pressure is removed, the walls sepa- 
rate slowly from the mass, giving a sensation of sticki- 
ness (adhesive sympton). When the faecal mass is 
hard, these symptoms may be absent, and the feel may 
closely simulate that of a cancerous tumor. 

Next to the appendicular region, the most frequent 
site of tumors is the left iliac region. The most com- 
mon tumors here are inflammatory thickening of the 
intestine secondary to diseases causing ulceration. 
Inflammatory thickening of the sigmoid flexure fre- 
quently causes it to be felt as a hard, well-defined, rope- 
like mass. Faecal impaction and malignant disease in 
this region have the same features as elsewhere. 

In examining the intestinal tract by palpation, in 
addition to tumors, sensitive and painful areas must be 
noted. The different portions of the canal vary greatly 



PALPATION. 409 

in their sensitiveness to palpation. It is most sensitive 
in the region of the csecum, and epigastrium midway 
between the ensiform cartilage and umbilicus. The 
entire canal may become sensitive in acute intestinal 
irritation, whether inflammatory or not. Local inflam- 
mation of the intestine causes increase in sensitiveness, 
and when the peritoneum is involved there is localized 
pain, with increased rigidity of the overlying muscles. 

Differential Diagnosis. — In addition to the tumors 
already noted, the ilac regions may be invaded by tumors 
from the pelvic organs, as ovarian tumors, cysts, espe- 
cially of the broad, ligaments, pelvic abscess, extra- 
uterine pregnancy, or by hernias and abscess burrow- 
ing along the psoas muscles. These are differentiated 
usually by vaginal examination. 

Pelvic Organs. — Tumors may arise from the uterus 
and adnexa. Tumors of the uterus may be due to 
pregnancy, fibro-myomata or fibroids. In pregnancy 
the tumor is ovoid, smooth, freely movable laterally, and 
in proportion as it extends above the pelvic brim the 
diagnostic signs of contractions and 'foetal movements are 
detected. Distension of the uterus from retained men- 
strual flow and from growths may give the contractile 
symptoms of pregnancy. 

Fibroid tumors of the uterus may simulate pregnancy, 
as far as size, shape and mobility are concerned, but 
they lack the contractile sign. When they involve only 
one portion of the uterine wall they give an irregular 
tumor. 

Ovarian tumors are usually felt in the iliac regions, 
and as they increase in size assume more the medial 
position. They are usually cystic, and have a round, 
smooth, elastic feel. Fluctuation can at times be 
detected. Examination per vaginam shows their rela- 
tion to the broad ligaments and uterus. They are differ- 
entiated from ascites and renal tumors by percussion. 

Parovarian cysts have many features of ovarian cysts. 
As they are usually thin-walled, fluctuation is a marked 
symptom. 



410 THE ABDOMINAL ORGANS. 

Distended bladder may give a tumor occupying the 

lower portion or the entire abdominal cavity. Its shape, 
smoothness and elasticity cause it to simulate ovarian 
tumors, ascites, pregnancy and pancreatic cysts. The 
possibility that a large abdominal tumor occupying the 
median position may be a distended bladder should 
always be borne in mind, and the viscus should be 
examined by catheter before excluding this condition. 



CIIAPTEE XVII. 

PERCUSSION. 

By percussion it is possible to outline the borders of 
the solid organs of the abdomen, and by the relative 
degree of dullness or flatness to determine their relation 
to the air-containing (resonant) organs of the thoracic 
and abdominal cavities. 

When two solid organs are in contact, as the left lobe 
of the liver and heart, it is impossible to define their 
borders by simple percussion, although at times ausculta- 
tory percussion aids in doing this by showing slight dif- 
ferences in the percussion note. The borders of the 
stomach, large and small intestine, can be determined 
only approximately, as will be explained later. 

For percussion the posture of the patient is the same 
as described under Palpation. The fingers should 
always be used both as hammer and pleximeter. The 
strength of the percussion stroke should be regulated 
according to the nature of the organ percussed, whether 
solid or hollow, and its relation to the surface and to 
organs and tumors giving a different note. The per- 
cussion note is still further modified by the nature of 
the parietes, as the abdominal cavity is inclosed in part 
by the bony thorax and in part by the abdominal walls, 
varying in thickness and tension. As there is marked 
normal regional variation, it is necessary to be thor- 
oughly familiar with the percussion sounds present in 
the usual anatomical divisions of the abdomen. 

Left Hypochondrium. — This region includes that por- 
tion of the abdominal cavity lying beneath the ribs on 
the left side of the body. The vault of the diaphragm 



412 THE ABDOMINAL ORGANS. 

rises as high as the level of the fifth rib. The upper 
portion of this area is occupied by the thoracic viscera 
— heart and lungs, and by the abdominal organs — 
left lobe of the liver, stomach and spleen — and the per- 
cussion sound varies accordingly. Over that portion 
where the heart and liver are parietal the note is flat. 
Just below the area of flatness, toward the edge of the 
costal arch, the thin left lobe of the liver gives a super- 
ficial dullness on light percussion, while on forcible 
percussion a tympanitic quality can be obtained from 
the underlying stomach. To the left of the area of 
cardiac and liver flatness the lung is parietal from the 
fifth to the low r er border of the sixth rib, and the sound 
is that of pulmonary resonance, with added tympanitic 
quality from the stomach. The proportion of the two 
sounds varies with the force of the percussion and the 
condition of the stomach and lung, pulmonary resonance 
increasing when the lung is overdistended, as in full 
inspiration or emphysematous dilatation ; diminishing 
with retraction of the lung from any cause, and becom- 
ing flat when the complemental space of the pleura is 
filled by effusion. Distension of the stomach or dis- 
placement upward of this organ by increased abdominal 
pressure causes a relatively higher position of the dia- 
phragm and corresponding increase in stomach reso- 
nance. 

Hai.f-Moojst Space (Traube). — This embraces all 
that portion of the lower thorax below a concentric line 
starting from the cardio-hepatic flatness in the sixth 
interspace, and extending downward to the anterior 
axillary line or mid-axillary line, which corresponds 
approximately to the lower border of the lung. In this 
space the stomach is parietal, and the note is high 
pitched and tympanitic, with a peculiar metallic, echo- 
like quality (stomach tympany). 

The percussion note over this space may be altered by 
a number of conditions. (1) The upper boundary may 
be invaded by pulmonary resonance, due to increase in 



PERCUSSION, 413 

size of the lung', with depression of the diaphragm. 
(2) It may be flat from depression of the diaphragm by 
pleurisy with effusion. (3) The normal stomach 
tympany may be replaced by flatness, due to the filling 
of the organ with food or liquid. (4) Enlargement 
anteriorly of the left lobe of the liver from any cause 
may give an area of flatness or dullness. (5) Toward 
the axillary line in the region of the ninth to the eleventh 
rib enlargement of the spleen may give dullness or 
flatness. (6) Distension of the colon may give change 
in the tympanitic sound. 

The Splenic Area. — This area is to the left of the 
half-moon space, and limits it in that direction. Although 
the spleen is contained in the abdominal cavity, with its 
long axis parallel to the tenth rib, and occupying the 
space between the ninth and the tenth ribs from the 
mid-axillary line in front to within 1% to 2 inches of 
the vertebral column behind, under normal conditions 
but a small portion of its anterior border approaches the 
surface. On account of its respiratory and passive 
mobility, its position and corresponding effect on the 
percussion note will vary according to the posture of 
the patient. When lying on the back, it is displaced 
posteriorly; when lying on the right side, it is more 
anterior, but further removed from the surface. In the 
erect posture its position is more nearly horizontal, and 
slightly lower. It is impossible to accurately outline 
the normal spleen by percussion, surrounded and in part 
overlapped as it is by air-containing structures. The 
dullness obtained is only relative to the pulmonary 
resonance above and stomach tympany anteriorly, intes- 
tinal tympany below and flatness of lumbar muscles and 
kidney posteriorly. 

To determine the splenic area dullness, the percussion 
blow must vary according to the nature and condition of 
the overlying structures. Over the portion covered by the 
lung, beginning beyond the normal area, the percussion 
is first made toward the spleen with fairly strong blows 



414 THE ABDOMINAL ORGANS. 

until slight deep-seated relative dullness is detected. 
From this point the percussion proceeds with gradually 
diminishing force. From the gastric and intestinal 
borders only light percussion is used. In the normal 
condition of the lung, with stomach and intestine empty 
and not distended with gas, a small area of splenic dull- 
ness may be detected in the mid-axillary line or between 
it and the post-axillary line and between the lower edge 
of the ninth and upper edge of the eleventh ribs. Beyond 
this area the splenic dullness becomes progressively 
masked by increased pulmonary resonance as percussion 
proceeds toward the posterior border. 

The size and position of the area of splenic dullness 
varies with the respiratory movements, being larger at 
the end of expiration and smaller or disappearing dur- 
ing inspiration. On account of the relation of the 
spleen to surrounding organs, the normal area of splenic 
dullness may be replaced (a) by increased resonance ; 
(b) increased dullness or flatness. Increased resonance 
over the splenic area may be due to depression of the 
lower border of the left lung, dependent upon emphy- 
sema or to distension of the stomach and intestines, large 
and small, with gas (tympanites). Diffused dullness 
in the splenic area may be caused by consolidation of the 
lung overlapping the spleen, left pleural effusion or 
pleural thickening; fluid distending the stomach, or fill- 
ing of the transverse portion or splenic flexure of the 
colon with feces ; also by general ascites. Absolute 
increase in splenic dullness occurs in all enlargements of 
the spleen, and when that organ becomes more parietal. 
On account of the effect of surrounding organs upon 
splenic dullness, the diagnosis of enlargement of the 
spleen should not be made by percussion alone, but the 
results should be corroborated by palpation. 

Eight Hypochondrium. — In the right hypochondrium 
all of that portion of the abdominal cavity that is 
covered anteriorly by the thorax is occupied by the liver, 
the upper border of which rises as high in the mammary 



PERCUSSION. 



415 



line as the fifth rib, corresponding to the dome of the 
diaphragm. 

Percussion over the liver gives two areas. The first 
corresponds with that portion which is separated from 

the thoracic wall by the lnng — the area of relative dull- 
ness ; and the second, that portion where the liver is 
parietal — the area of liver flatness. 



Fig. 72. 




Absolute and relative heart and liver dullness, also regional variation 
in thorax. 



The pnenmo-hepatic border of the liver corresponds 
to a line that separates the relative hepatic dullness 
from hepatic flatness. The position of this border and 
the area of hepatic flatness will vary according to the 
condition of the right lung, the border being lower and 
the area of hepatic flatness smaller with full inspiration 
and in emphysema, and the border being elevated with 



416 THE ABDOMINAL ORGANS. 

increase in the area of flatness in expiration and diminu- 
tion of the size of the lung. The relative liver dullness 
cannot be detected over the entire upper portion of the 
liver, as the pulmonary tissue is too thick for the liver 
to be reached by the percussion vibration. (Fig. 72.) 

The point at which the influence of the underlying 
liver upon pulmonary percussion will be detected will 
depend markedly upon the force of the percussion blow, 
which will also influence the determination of the 
pneumo-hepatic border. Proceeding from above down- 
ward, the percussion blows should be progressively 
lighter as the lower border of the lung is approached, 
where only the lightest stroke should be employed. 

The pneumo-hepatic border should be determined by 
percussion from the area of relative dullness to absolute 
flatness, and also beginning over the flat area by per- 
cussing toward the area of relative dullness until faint 
resonance is detected. Normally the pneumo-hepatic 
border extends from the base of the ensiform cartilage 
in the median line to the upper border of the sixth rib 
in the mammary line, and to the eighth rib of the mid- 
axillary line. Well-marked liver dullness extends one 
or more interspaces higher, gradually shading off into 
pure pulmonary resonance. 

The area of absolute flatness on the anterior portion 
of the chest extends from the pneumono-hepatic border 
to the free border of the ribs. Over the lower portion 
the thinness of the liver permits percussion vibration to 
reach the underlying air-containing organs, and gives 
a slight tympanitic quality to the note. 

Conditions Modifying the Area of Flatness 
Over the Liver. — The area of liver flatness may be 
enlarged upward by : 1. Changes in the thoracic organs 
due to (a) consolidation of that portion of the lung over- 
lying the liver, (b) Retraction of the lung, causing 
greater portion of the liver to become parietal. (c) 
Effusion into the right pleural cavity or thickening of 
the pleura. 2. Displacement of the liver upward from 



PEBCUSSION. 417 

any cause. In this condition the lower edge of the liver 
is also raised above the normal limit. 3. Absolute en- 
largement of the liver, which may be uniform or irreg- 
ular, corresponding to the conditions noted under Pal- 
pation. In these conditions the enlargement of the liver 
upward is not so great as downward, except when 
secondary changes produce increase in the intra-abdomi- 
nal pressure and displacement upward of the liver and 
diaphragm. 

In irregular enlargements or tumors, the outline 
corresponds to the location of the tumors. 

Extension of the area of flatness downward may be 
due to displacement from thoracic disease, causing 
descent of the diaphragm and liver. In this condition 
the liver may be forced down below the free edge of the 
ribs, and the area of absolute dullness is only relatively 
increased, the pneumono-hepatic border being also 
depressed. Absolute enlargement of the liver, uniform 
or irregular, causes the area of flatness to extend accord- 
ing to the change occurring in the liver. 

Solid tumors or fluid extending to the liver cause the 
flatness to extend beyond the normal liver area. 

Decrease in the area of hepatic flatness may be 
apparent or absolute. It is seemingly diminished 
whenever the area of normal flatness is encroached upon 
by distension of the lung above or by the stomach or 
intestine below. The greatest diminution in the size of 
the liver occurs in cirrhosis and in acute yellow atrophy. 

The True Abdomen. — Percussion of all the anterior 
portion of the abdomen not inclosed by the thorax gives 
a tympanitic note, due to the underlying air-containing 
organs. In the epigastrium the stomach is overlapped 
by the left lobe of the liver, which is too thin to prevent 
the percussion vibration reaching the stomach. On 
light percussion, slight dullness due to the liver may be 
detected. 

The percussion note obtained over the stomach, large 
and small intestines, is tympanitic in quality, and varies 
27 



418 THE ABDOMINAL ORGANS. 

slightly in pitch over the different segments, according to 
the amount of air contained and the tension of the walls ; 

hut it is difficult to determine accurately the outline of 
the stomach and large and small intestines, on account 
of their varying size and degree of distension. 

To determine the lower border of the stomach, it is 
examined when filled with fluid or artificially distended 
with air. When the patient is in the recumbent posture, 
the fluid gravitates to the most dependent portion; the 
note obtained over the viscus on percussion is tympa- 
nitic, and its lower limit is separated from the adjacent 
large intestine by a difference in pitch. The patient 
then assuming the upright position, the fluid — the 
amount of which may be increased by drinking water — 
causes the lower segment, which was previously tym- 
panitic, to become flat on percussion. 

Distension of the stomach bv forcing air through a 
stomach tube, or by the production of carbon dioxide by 
having the patient drink separately a solution of tartaric 
acid (oss) and one of bicarbonate of soda (oss), causes 
the note to become markedly tympanitic and ringing. 
When it is not safe to cause forcible distension of the 
stomach, the large intestine may be distended by forcing 
gas from a Davidson syringe into the rectum, and so 
causing a difference in the pitch of the distended colon 
from that of the more relaxed stomach. 

Cox t ditioxs Modifying Abdomixal Resonance. 
Thickexed Abdomixal Walls. — Increased thickness 
of the abdominal walls, especially when due to fat, and 
also accumulations of fat in the omentum (omental 
lipoma), cause a slight diminution of resonance over the 
entire abdomen, which, however, is not sufficient to 
obliterate the tympanitic resonance of the stomach and 
intestines, but which masks the normal outline of the 
solid organs and renders the detection of tumors difficult, 
especially when they are small and not entirely parietal. 

Fluid ix the Abdomixal Cavity, Ascites. — A 
small amount of fluid does not modify the percussion 



PERCUSSION. HO 

note over the abdomen, aa the fluid gravitates to the most 
dependent portion, according to the posture. When 
sufficient in amount to rise above the symphysis in the 

erect position and above the heavy muscles of the flank 
in the recumbent posture, it gives a flat note where it is 
parietal, and, as the intestines are floated on the surface 
of the liquid, a tympanitic note is found above its level, 
which is always horizontal. 

As the fluid moves freely in the abdominal cavity, the 
line of flatness and the area of tympany change with 
alteration of posture. As the fluid gives a flat note, like 
that of solid organs, it is always necessary to change the 
position of the patient in determining whether or not 
the extension of dullness beyond the normal limits is due 
to effusion into the abdominal cavity or to absolute 
increase in size of the solid organs. 

When the abdominal cavity is extensively distended 
with fluid, or when the fluid is encapsulated, free move- 
ment may not occur. Although usually the intestines 
float above the fluid, adhesions or short mesentery may 
bind them down so as to prevent this. 

The relation of the area of tympanitic resonance to 
that of flatness is important in differential diagnosis of 
flatness due to ascites from abdominal tumors. In 
ascites, with the patient in the recumbent posture, the 
area of tympantic resonance occupies the centre of the 
abdomen around the umbilicus, changing position with 
that of the patient, and always resuming the uppermost 
position ; while in solid tumors which are parietal the 
dullness occupies the most prominent portion of the 
abdomen, and is surrounded by tympanitic resonance, 
which does not change with altered posture. 

Abdominal. Tumors. — Abdominal tumors cause 
diminution in resonance according as they are parietal. 

Tumors of the stomach and intestine are rarely lar.o;e 
enough to give well-marked flatness, although when 
associated with thickened peritoneum there may be a 
slight diminution of resonance. 



420 



THE ABDOMINAL ORGANS, 



Frccal accumulations in the large intestine mav be 
detected by percussion, as they are usually parietal. 
They may easily be detected when they occupy the 



Fig. 73. 



Fig. 74. 




Flatness 



Tumor of spleen. 
-Resonance between posterior margin 
and lumbar muscles. 



Tumor of left kidney. 



caecum, the ascending colon or che sigmoid flexure. 
When situated in the hepatic or splenic flexures, they 
increase the areas of dullness of liver or spleen. 



PERCUSSION. 



421 



Enlargements of the liver and spleen, when they 
extend beyond the ribs into the abdominal cavity, give 
well-marked areas of flatness, sharply defined by the 
surrounding intestines. The enlarged organs are parietal, 
but it is only in exceptional conditions that a portion of 
the intestine intervenes between it and the abdominal 
wall. Tumors springing from the under surface of the 
liver, as hydatids, or irregular enlargements, as cancer, 
may have intestine in front. 

Posteriorly the liver dullness does not extend to the 
spine, but well-marked splenic dullness may extend to 
the spine in the upper portion, while lower down there 
is an area of resonance between the tumor anteriorly 
and the edge of the lumbar muscles posteriorly. (Fig. 
73.) 

Tumors of the kidney are not parietal throughout, 
and the area of flatness is usually divided by the colon 
in front of it. Posteriorly the flatness extends to the 
spine throughout. (Fig. 74.) 

In tumors of the pelvic organs the dullness extends 
upward from the pubic arch, and is surrounded by 
intestinal resonance in the flank and above. Dullness 
over the tumors may be diminished by distension of the 
intestine with gas (meteorism) or by air in the peri- 
toneal cavity (perforative peritonitis). 

When dullness in the flank is present, not extending 
also to the central zone of the abdomen, with resonance 
between the dullness and the central portion of the 
abdomen and the pelvic brim, the tumor is not of pelvic 
origin, but is from the deeper tissues (pancreas, retro- 
peritoneal glands, etc.). 



CHAP TEE XVIII. 
AUSCULTATION. 

Auscultation of the abdominal organs gives very 
little aid in differential diagnosis, and is limited to (a ) 
splashing sounds made in hollow organs containing both 
air and fluid; (b ) gurgling, churning or cooing sounds, 
due to passage of fluid through the intestinal canal; 
(c) friction sounds, produced by the roughened peri- 
toneum over solid or hollow organs which move with 
respiration ; (d) vascular or hremic sounds. 

(a) Splashing sounds (succussion) may be heard over 
the stomach and large intestines when they are agitated 
with short, sharp blows with the tips of the fingers. 

In the stomach this occurs when the viscus contains 
both air and fluid and is to a certain degree relaxed. It 
was formerly considered diagnostic of gastroectasis, but 
can occur without any pathological condition of the 
stomach being present. Its chief value as a sign of 
enlarged stomach is in finding it persistently below the 
normal limit of the stomach. 

Over the caecum, on account of the liquid character of 
its contents, succussion sounds may also be produced. 
When found beyond the head of the c^cum, especially in 
the transverse portion of the colon, it indicates an abnor- 
mally liquid state of the fecal mass in these locations. 
In the small intestine succussion cannot be induced. 

( b) Gurgling or churning sounds are heard over the 
stomach and intestines, due to the passage of liquids 
from the narrowed portions into the wider areas beyond. 
Over the cardia, normally, a hissing murmur is heard 
soon after swallowing liquids. In obstruction at the 



AUSCULTATION, 423 

cardia from any cause, the normal deglutition sound 
may be replaced by a gurgling or rushing sound occur- 
ring at a relatively later period, and due to the forcing 
of the contents of the (esophagus through the obstruction. 

Over the small and large intestines, normally, cooing, 
gurgling sounds are heard. When the intestines are 
distended with gas and the peristaltic activity is 
increased, this may become loud enough to be heard at 
some distance from the patient. 

In tympanites with lessened peristalsis, as occurs in 
paralysis of the intestines, and in peritonitis, absence of 
this normal sound in proportion to the distension is of 
diagnostic importance. 

Over the ileo-ca^cal valve, gurgling can frequently be 
heard on firm pressure. This has been frequently cited 
as one of the symptoms of typhoid fever, but it is not 
pathognomonic of this disease, as it occurs whenever the 
contents of the small intestine are more liquid than 
normal and when there is slight distension of the ileum 
with gas. 

(c) Friction sounds are heard whenever the peritoneal 
coats are covered with inflammatory exudate and there 
is free movement between the surfaces. This is most 
marked in perihepatitis and perisplenitis, provided the 
normal respiratory mobility of the liver and spleen is 
not interfered with. It is rarely heard over hollow 
organs, although in acute localized inflammation of the 
stomach it may be present. The quality of the sound 
will vary according to the character of the exudation. 
In fibrinous exudation it occurs as fine, crackling rales. 
When adhesions are present, creaking, crumpling fric- 
tion sounds may be heard. 

(d) Vascular or haemie murmurs may be heard over 
different portions of the abdomen. Solid tumors and 
growths pressing on the aorta or large blood-vessels may 
cause sufficient narrowing to induce a murmur, which 
is conveyed by the tumor to the surface, and is heard as 
a bruit, synchronous with the first sound of the heart, 



424 THE ABDOMINAL ORGANS. 

or it may be a little delayed. Aneurismal dilatation of 
the aorta or abdominal vessels may cause a similar mur- 
mur to be heard. They are differentiated from pressure 
murmurs by the presence of expansile pulsations. 

Over the liver a systolic murmur may he beard, due 
to the conveyance of tricuspid regurgitant murmur,. 

In tumors of the uterus, arterial sounds may be 
present. In pregnancy, in addition to the uterine 
souffle, there is heard the foetal heart beat. Uremic 
sounds, simulating the uterine souffle, may also be heard 
in extra-uterine pregnancy and in vascular tumors of 
the uterus, but the foetal heart sound is not heard.. 



PART V. 
EXAMINATION WITH X RAT. 



For making X-ray examination of the body, it is 
necessary to have apparatus of great power, and also 
means for adjusting the quality of the ray emitted by 
the tube, which may be accomplished either by inserting 
a series of spark caps in the circuit connecting the tube 
or by adjusting the vacuum of the tube. There are on 
the market a number of tubes provided with vacuum 
regulating devices, all of which depend for their action 
upon the liberation of a little gas from some salt which 
is contained in a small chamber connected with the tube. 

The exciting apparatus maybe either a static machine, 
an ordinary induction coil, or a coil of high frequency 
type. If an induction coil is used, it should be capable 
of delivering heavy sparks, 10 or 15 inches long, and 
should be provided with means for giving very rapid 
interruptions of the primary circuit. The turbine mer- 
cury interrupters and the liquid or electrolytic interrup- 
tions are available for this purpose. The induction 
coil has the advantage that it occupies a comparatively 
small space, and its action is not affected by the weather. 
If the static machine is used, it should be of a rather 
large size, having, for example, 10 to 16 revolving plates 
of about 30 inches diameter. The static machine gives 
a very steady excitation of the Crookes tube, and is 
therefore very satisfactory for fluoroscopic examina- 
tions. It is, however, more or less susceptible to 
changes in weather conditions. 



4:26 EXAMINATION WITH X RAY. 

On account of the constant movements of respiration, 
the fluoroscope examination of the thoracic viscera is 
perhaps more satisfactory than the radiograph. Much 
valuable information may be obtained by observing the 
movements of the parts, as, for example, the excursions 
of the diaphragm, the pulsations of the heart or of 
aneurism, the change of level of fluid in the pleural 
cavity, due to change of position of the subject, etc. 
The facility with which these examinations can be made 
and the accuracy of their findings will vary with dif- 
ferent subjects. Obviously, a small, thin subject will 
give a more satisfactory fluoroscopic picture than a large, 
muscular one. At first it may seem that by increasing 
the intensity and penetrating power of the rays we could 
examine a large subject as well as a small one, but this 
is not the case. It is easy enough to produce X rays 
of sufficient intensity to penetrate any human body, but 
in order to make a satisfactory fluoroscopic examination 
or radiograph it is necessary that these rays be inter- 
cepted to varying extents by the different structures 
under examination, so that they will cast shadows of 
discriminate density. A thick layer of muscular or 
adipose tissue, although it may transmit the ray, to a 
certain extent confuses the shadow of substances of less 
capacity which lie beneath it ; hence it is impossible to 
differentiate the tissues under examination by increas- 
ing the power of the X rays. 

Fluoroscopic examinations should be made in a dark- 
ened room. It will be found that it takes the average 
eye from five to fifteen .minutes to adjust itself so as to 
use the fluoroscope to the best advantage. All clothing 
should be removed from the patient, and the examina- 
tions can be conveniently made with the patient in a sit- 
ting position, with the arms resting over the head, so as 
to draw the scapuhe away from the median line. It is 
well to have two fluoroscopes- — a large one, which will 
show the entire region, and a small one, with which 
small parts may be examined and the light from a large 



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El 
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PLATE VII. 




R 



Radiograph, of Diffuse Tuberculosis of the Left Lung 
(Fibroid changes very marked). 



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P 

S3* 



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P 

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S3* 

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S3* 







EXAMINATION WITH X UAY. 427 

area excluded. Sometimes it will be convenient to 
examine the patient in a recumbent position. In this 
case it is well to place the subject on a stretcher, placing 
the tube underneath and the fluoroscope above. The 
canvas of the stretcher offers very little obstruction to 
the X ray. A protective screen of thin aluminum is 
sometimes interposed between the X-ray tube and the 
subject under examination, to prevent any burning by 
the rays. This screen offers very little obstruction to 
the X ray, and therefore interferes very little with the 
examination. 

For the reasons pointed out above, the radiograph of 
the thorax will usually not be so satisfactory as the 
fluoroscopic examination, though it may be valuable as a 
permanent record. The apparatus required for making 
the radiographs will be practically the same as those 
described for fluoroscopic examinations, with the addi- 
tion of necessary plates, etc. 

Observation by means of the X ray of the thorax and 
abdomen presents many points of interest to the 
clinician. A thorough knowledge of the normal appear- 
ance of the different parts of the body under the X ray 
is absolutely necessary for the proper use of the fluoro- 
scope, and for correct interpretation of the skiagraphs 
as a means of diagnosis, otherwise false interpreta- 
tion will be made. The use of the X ray in medicine 
should be accompanied by the use of other methods of 
diagnosis, and should never be relied upon alone. 

For the beginner, the subject to be examined should 
be carefully selected. A young person, preferably an 
adult male about twenty years old, and not too fleshy, is 
the best. It should be constantly borne in mind that 
each subject will present a picture that has certain 
individual peculiarities, according to the thickness of 
the soft parts, the bony structures and antero-posterior 
diameter of the chest. The fluoroscope has many advan- 
tages over the skiagraph for a beginner, as the outlines 
are more distinct, and it is possible, by varying the 



428 EXAMINATION WITH X EA )'. 

intensity of the light, to obtain a Letter view of the 
thoracic and abdominal organs and to determine their 
outlines. 

The Normal Picture. — As in other methods of diagno- 
sis, the examination should be systematically conducted. 
At first a general inspection of the thorax from above 
downward is made. The picture upon the screen shows 
in the median line corresponding to the sternum, spinal 
column and mediastinal spaces, a dark shadow at the 
level of the third rib, which widens out into a more or 
less spherical figure, corresponding to the ventricles, and 
resting on the dome of the diaphragm, which appears as 
a dark line. On either side of this central shadow ap- 
pears a light field, corresponding to the pulmonary tis- 
sue, which should present a thin, foggy, uniform shadow, 
varying during the phases of the respiratory act, being 
lighter on full inspiration and darker at the end of 
expiration, according to the rarefaction of the lung. 
Traversing the light area of pulmonary tissue, the ribs 
are noted, their prominence varying with the intensity 
of the light used. Beyond the thorax, the bony 
structures and soft parts are readily distinguishable. 
(Plates III and IV.) 

In addition to the outline of the organs above men- 
tioned, the extent of their motion should also be noted. 
Ventricular contraction is well defined, also slight pul- 
sation of the aorta can be seen. The line of the dia- 
phragm varies with the respiratory act, descending with 
inspiration, when the complemental spaces of the pleura 
become distinguishable as a transparent area. The 
movements of the diaphragm should be uniform, both 
sides acting simultaneously and to the same extent. 
With the descent of the diaphragm and rarefaction of 
the lung, the cardiac position changes and the outline 
becomes more distinct. 

The Effect of Changes in the Lung on the Fluoroscopic 
Picture. — These may cause the shadows to be more 
intense and darker when the density of the lung is 



EXAMINATION WITH X HAY. 429 

changed by increase in tlie normal structure or by fill* 
ing of the alveolar spaces; or the opposite when rarefac- 
tion of the lung occurs from increased size of the 
alveolar spaces, or when there is destruction of tissue 
with cavity formation. They may also cause change in 
the movements of the diaphragm and in the position of 
the heart and mediastinal structures. 

Conditions Causing Dark Areas. — Tuberculosis. It 
should be borne in mind that the right apex is not so 
markedly transparent as the left. This corresponds to 
the normal variation noted under palpation, percussion 
and auscultation. The amount of darkening will corre- 
spond to the degree of change. (Plates V and VI.) 

As in other methods of examination, the fluoroscopic 
picture of the two sides is comparative, and should 
always be judged on this basis. When the tubercular 
area is central and surrounded by emphysematous lung, 
the shadow of the affected portion is more pronounced. 

In the incipient cases a slight denseness in the shadow 
will be observed in one apex when carefully considered 
in comparison with clearness of the normal shadow, and 
with the apex on the other side. As the pathological 
process extends until consolidation or cavity results, the 
shadow will progressively become deeper and larger 
until the change on the two sides is very marked. The 
fibroid changes are evident by the absence of the normal 
foggy shadow and by a more dense shadow over the areas 
involved. (Plate VII.) This condition is often 
noticeable in the lower portion of the chest, secondary to 
the diaphragmatic involvement. Retraction and thick- 
ening of the pleura give a darker shadow, and marked 
loss of motion over the affected area. (Plate VIII.) 

Pneumonic consolidation. In lobular pneumonia 
the dark areas correspond to the site of the lesion, and 
have the same general appearance as those of tubercular 
infiltration. Croupous pneumonia gives a well-defined 
shadow, corresponding to the degree of consolidation 
and the division of the lobes. Radioscopy aids greatly 



430 EX. 1 MIX. i TJON WITH X EA Y. 

in differentiating pneumonia from primary or compli- 
cating effusion, showing the relation of the lung to the 
diaphragm. In pneumonia, on full inspiration, the 
descent of the diaphragm shows a light line between the 
lung and the moving shadow of the diaphragm. When 
effusion occurs, primary or secondary, this line is not 
seen. Pleural effusions cause a uniform dark shadow. 
The character of the fluid does not influence this shadow. 
In addition to the shadow caused by the fluid, it is 
possible to determine the line that the fluid assumes in 
the chest and the amount of displacement of the thoracic 
viscera. 

Calcareous deposits in the lung or fibroid thickening 
also cause slight shadows. The bronchi may give an 
ill-defined shadow on either side of the median dark 
space, and must always be considered. Enlargements 
of the glands cause shadows to appear. 

Conditions Causing Lighter Shadows. — The lung 
transmits light more readily in emphysema, and 
there is less change of shadow during respiration. 
The movements of the diaphragm are not as great; 
the heart appears unusually clear, and also assumes the 
typical position. In pneumo- and hydro-pneumothorax 
the shadow is less marked over that portion of the pleura 
which contain air (Plate IX), while when fluid is pres- 
ent a dark shadow is seen below its level. The upper 
level assumes a horizontal line, in contradistinction to 
the curved line seen in simple effusion. In hydro- 
pneumothorax the splashing of the fluid is plainly seen 
on shaking the patient, and also the change of level on 
his changing position. The pulmonary shadow is pres- 
ent above the level of the fluid, and is slightly deeper in 
density, owing to the compression. In pneumothorax 
the lack of motion of the diaphragm during inspiration 
is the most striking feature. The displacement of the 
heart and the relatively denser shadow of the opposite 
lung are diagnostic. Cavity formation also gives a well- 
marked light area. When the walls of the cavity con- 




It" 

M 



EXAMINATION WITH X RAY. 431 

tain calcareous deposit, or the cavity is surrounded by 
consolidated lung, a shadow may replace the light area. 

Examination of the Circulatory System. — For satisfac- 
tory examination of the borders of the heart, the lung 
and pleura must be clear. Normally a dark shadow is 
caused by the ventricles, while the right auricle causes 
a faint shadow to be seen just to the right, and on the 
left a fainter shadow is caused by the left auricle. The 
rarefaction of the lung causes these shadows produced 
by the auricles to become clearer, so that they are more 
pronounced at the end of full inspiration than in expira- 
tion, and also in emphysematous dilatation than in nor- 
mal lung. Dilatation of the cavities or distension by 
blood causes a correspondingly darker shadow. As has 
been mentioned, the intensity of the shadows will vary 
according to the amount of light used. The pulsations 
of the heart and aorta may be seen, especially during 
inspiration. 

The exact cardiac outline can be mapped out on the 
chest by means of an indelible pencil; the lower end 
encircled in the metal cylinder. After carefully outlin- 
ing the heart and locating the apex, the tracing can be 
made direct from the chest wall. The tracing should 
include the nipple and one or two bony parts of the 
chest. This chart can be filed and retained as a perma- 
nent record. (See Fig. 66.) 

Cardiac Diseases. — The fluoroscope, in selected cardiac 
cases, will materially assist in determining the cardiac 
area, shape and relation to the surrounding viscera. In 
the following diseases important points will be enumer- 
ated in detail : 

Pericarditis with Effusion. — The fluid in peri- 
carditis changes the shape of the cardiac shadow, giving 
the broad base below; the pulsating apex is less 
visible. A point of great value in this condition can 
be noted on deep inspiration ; as the diaphragm descends 
the pericardium can be seen to pull away from the 
cardiac mass, and is distinguished by the slight change 



432 EXAMINATION WITH X KAY. 

in density between the pericardial fluid and the cardiac 
wall. 

Adhesive Pericarditis. — The displacements due to 
retraction are visible, and also those which occur when 
the pericardium is displaced by fibroid changes in the 
lung. 

Hypertrophy and Dilatation. — Changes in size 
and in the shape of the cardiac shadow can be, by means 
of the scheme outlined above, readily observed and 
recorded accurately for future observation. (Plate X.) 

Mitral Stenosis. — The change in the shape of the 
heart in this condition is very noticeable. The axis of 
the shadow is changed ; the apex is carried upward and 
to the left, and the long diameter is almost parallel with 
the diaphragm. 

Aneurism. — The localization of aneurism at the 
base of the heart, or involving the arch of the aorta, is 
probably one of the most important results of fluoro- 
scopic work. The bulging of the vascular wall can be 
noted accurately, and its relation to the base of the heart 
or great vessels plainly demonstrated. (Plates XI and 
XII.) 

The Radiograph in Cardiac Diseases. — The radiograph 
in cardiac diseases has been of much less assistance than 
the fluoroscope, yet, where available, it places in our 
hands an absolute picture of the conditions under con- 
sideration. In many subjects a radiograph can be 
obtained which will determine the outline and position 
of the heart, location and size of the aneurisms of dif- 
ferent portions of the aorta. 



PLATE XII. 




B, 



Radiograph of Aneurism of Ascending Portion of Thoracic Aorta. 



INDEX. 



Abdomen, auscultation of, 422 
decrease in size of, 381 
enlargements of, 377 
causes of, 377 

local, 379 
epigastric region, 379 
hypogastric region, 380 
lateral region, upper left, 380 
right, 380 
lower left, 381 
right, 380 
umbilical region, 379 
inspection of parities, 376 
movements of, 376 
respiratory, 376 
visceral, 377 
percussion of, 411 
regional anatomy of, 33 
superficial limits of, 18 
true limits of, 18 

percussion of, 416 
tumors of, percussion over, 420 
Abdominal walls, palpation of, 
383 
tension of, 383 
tumors of, 383 
Abscess of liver, 396 

of spleen, 402 
Actinomycosis, 206 

condition of lung in, 206 
physical signs of, 206 
stages of, 206 
Adherent pericardium, 353 
cardiac sounds in, 361 
differentia] diagnosis of, 363 
friction sounds in, 361 
retraction of chest wall in, 
355 
Adventitious sounds, 112 



zEgophony, 137 

in pericarditis with effusion, 
360 
Alar chest, 41 
Amphoric breathing, 112 

resonance, 137 
Ansemia, arterial pulsations in, 
230 
pernicious, liver in, 395 
venous pulsation in, 231 
Ansemic murmurs, 277 

in pulmonic area, 340 
Aneurism of aorta, 365 

apex beat in, 367, 369, 370 
bruit in, 371 

bulging of chest wall in, 367 
cardiac sounds in, 371 
diastolic murmur in, 371 
differential diagnosis of, 372 
differentiated from aortic 
stenosis, 326 
from asthma, 191 
Drummond's sign in, 371 
dysphagia in, 369 
fluoroscopic examination of, 

432 
forms of, 365 
palpation, 240 
physical signs of, 367 
pressure signs in, 366 
pulsating tumor in, 367 
pulse in, 369 
Sanson's sign in, 371 
superficial veins in, 367 
thrill in, 368 
tracheal tugging in, 369 
traction of pupil in, 367 
of thoracic aorta, 229 
Aneurismal murmurs differen- 
tiated from pulmonary obstruc- 
tion, 341 



43 i 



INDEX. 



An^le of Ludovici, 19 
Aorta, aneurism of, 365 

apex beat in, 367, 369, 370 
bruit in, 371 

bulging of chest wall in, 367 
cardiac sounds in, 371 
diastolic murmur in, 371 
differential diagnosis of, 372 
differentiated from asthma, 

191 
Drummond's sign in, 371 
dysphagia in, 369 
physical signs of, 367 
pressure signs in, 366 
pulse in, 369 
Sanson's sign in, 371 
superficial veins in, 367 
thrill in, 368 
tracheal tugging in, 369 
traction of pupil in, 367 
arch of, 30 
percussion of, 265 
thoracic, aneurism of, 229 
Aortic diastolic murmurs, 291 
interspace, 19 

pulmonic, 19 
regurgitation, arterial pulsa- 
tions in, 230 
capillary pulse in, 230 
causes of, 328 
differentiated from mitral 

stenosis, 319 
effects of, 328 

location of apex beat in, 330 
murmurs in, 333 
physical signs of, 330 
pulsation of blood-vessels in, 

331. 
pulse in, 332 

water hammer, 332 
sound, accentuation of, 273 
stenosis, 320 

area of cardiac flatness in, 

324 
causes of, 320 
diagnosis of pathological 

condition in, 325 
differential diagnosis of, 326 
differentiated from tricuspid 

regurgitation, 348 
effects of, 321 
location of apex beat in, 322 



Aortic stenosis, murmur of, 324 
physical signs of, 322 
pulse in, 323 
thrill in, 323 
systolic murmurs, 289 

differentiated from pul- 
monary obstruction, 341 
valve, 31 
Apex beat, cause of, 222 

conditions modifying charac- 
ter of, 224 
extent of, 224 
location of, 224 
influence of abdominal 
changes on, 229 
bony thorax on, 224 
in children, 224 
in old age, 224 
changes in heart on, 227 
in lung on, 226 
in mediastinum on, 229 
in pericardium on, 227 
of soft parts on, 224 
of diseases of pleura on, 225 
location of, 222 

in aneurism of aorta, 367 

369, 370 
in aortic regurgitation, 330 
in aortic stenosis, 322 
in mitral regurgitation, 

305 
in mitral stenosis, 314 
in myocarditis, 350 
in pericarditis with ef- 
fusion, 354 
in pneumo-pericardium, 

364 
in tricuspid regurgitation, 
346 
palpation of, 234 

influence of bony thorax 
on, 235 
of cardiac changes on, 

237 
of changes in lung tissue 
on, 236 
in pericardium, 237 
in pleura on, 236 
of posture on, 234 
of soft parts on, 235 
in pulmonary regurgitation, 
342 



INDEX. 



435 



Appendicitis, 407 
Appendix, palpation of, 407 
Arterial murmurs, 297 
pulsations, 230 
in ADsemia, 230 
in aortic regurgitation, 230 
in chlorosis, 230 
conditions causing, 230 
cardiac, 230 
vascular, 230 
in Grave's disease, 230 
in rigid blood-vessels, 230 
Arterio-capillary fibrosis. See 

Arterio-sclerosis. 
Arterio-sclerosis, 374 
cardiac changes of, 374 
cardiac sounds in, 374 
murmurs in, 374 
physical signs of, 374 
stages of, 374 

superficial blood-vessels in, 374 
Artery, pulmonary, 30 
Ascites, 385, 418 
abdomen in, 386 
causes of, 386 

differential diagnosis of, 387 
fluctuation in, 386 
Asthma, 41, 186 
causes of, 186 
condition of lungs between 

attacks, 187 
condition of lungs during 

attacks, 186 
differential diagnosis of, 189 
physical signs of, 187 
Atelactasis, 163 
Ausculatory percussion, 94 
Auscultation of abdomen, 422 
sounds heard in, 422 
of abdominal organs, 422 
of the circulatory system, 266 
of cough, 137 
of the heart, 266 
of Inns:, 96 
methods of, 96, 266 

technique of, 97 
of thorax, 96 
use of stethoscope in. 266 
of uterus, 424 
Axillary region, 20 



B 

Barrel-shaped chest, 40 
Bell sound, 138 
tympany, 138 
Bladder, distended, 410 
Blood-vessels, impulse due to 
changes in, 229 
palpation of, 240 
pulsation of, in aortic regurgi- 
tation, 331 
rigid, arterial pulsations in, 230 
superficial, in arterio-sclerosis, 
374 
Brain, diseases of, irregular pulse 

due to, 252 
Breath sounds, alteration in 
duration of, 109 
in quality and pitch of, 111 
in rhythm in, 109 
amphoric, characteristic of, 

133 
blowing, 112 

causes of prolonged expira- 
tory, 109 
cavernous, characteristic of, 

133 
changes in intensity of, 108 
character of, 99 
conditions modifying con- 
duction of, by columns of 
air, 123 
conduction of, by air, 99 

by tissue, 100 
difference between inspira- 
tory and expiratory, 105 
dry rales in, 127 
effects of changes in bronchi- 
oles and alveoli on, 102 
of consolidation on, 131 
of plugging of bronchus 
on, 128 
exaggerated or compensa- 
tory, 123 
high-pitched, 112 
influence of bronchi on, 126 
of changes in pleura on, 139 
of increase in size of air 

spaces on, 132 
of increase of tissue in the 
walls of bronchi and 
alveoli on, 130 



436 



INDEX. 



Breath sounds, influence of 
larynx on, 124 
of movement of tidal air 

on, 123 
of tension on, 1*29 
of thoracic walls on, 140 
intensity of, 99 
laryngeal, 98 

modification of, in different 
divisions of bronchi, 100 
through tissue conduction, 
101 
moist rales in, 128 
normal, elements of, 104 

physiology of, 97 
regional variations of, 106 
tracheal 112 
tubular, 112 
types of, 107 
Broadbent's sign, 227 
Bronchi, influence of, on breath 
sound. 126 
position of, 22 
Bronchial breathing in pericar- 
ditis, with effusion, 360 
pure, 112 
Bronchiectasis, 153 
causes of, 153 

differential diagnosis of, 155 
differentiated from fetid bron- 
chorrhoea, 157 
from gangrene, 157 
from general bronchitis, 157 
from localized empyema 
opening into a bronchus, 
158 
from pulmonary abscesses, 

157 
from pulmonary tuberculosis, 
156 
physical signs of, 153 
Bronchitis, 141 
acute, 141 

differential diagnosis of, 147 
differentiated from acute 
diffuse pulmonary tuber- 
culosis, 148 
from broncho-pneumonia, 

148 
from chronic o?dema, 149 
physical signs of, 142 
chronic, 149 



Bronchitis, chronic, differential 
diagnosis of, 152 
physical signs of, 151 
varieties of, 150 
classification of. 141 
of the larger tubes, 141 
of the middle sized tubes, 142 
of the smaller tubes, 142 
of the smallest tubes, 142 
Bronchophony, 135 
Broncho-pneumonia, 161 

differentiated from acute 

bronchitis, 14^ 
phthisis. See pulmonary 
tuberculosis, acute 
Broncho-vesicular breathing, 111 
Bronchus, left, branches of, 23 
plugging of, effect on breath 

sounds, 128 
right, branches of, 23 
Bruit in aneurism of aorta, 371 



Caxcer of intestines, 408 
of liver, 396 
of pancreas, 390 
Capillary pulse in aortic regurgi- 
tation, 230 
Cardia, 34 
Cardiac dilatation. 34? 

differentiated from adherent 

pericardium, 363 
irregular pulse due to, 252 
dropsy. See Cardiac CEdema 
dullness, areas of, iufluence of 
bony thorax on, 262 
of cardiac changes on, 

264 
of changes in pericar- 
dium on, 263 
of lung on, 262 
of pleura on, 262 
soft parts on, 261 
normal, conditions modi- 
fying, 260 
outline of, 257 
in mitral regurgitation, 
307 
in consolidation of lung, 263 
in dilatation of heart, 264 
of left ventricle, 264 



INDEX. 



t37 



Cardiac dullness in emphysema, 
262 
in hypertrophy of heart, 264 
in hypertrophy of ventricle, 

264 
in pericarditis, 263 
in pericarditis with effusion, 

356 
in retraction of left lung, 263 
superficial and deep areas of, 

32 
in thickening of pleura, 263 
dyspnoea, characteristics of, 232 
differentiated from asthma, 
189 
from emphysema, 186 
types of, 232 
flatness, area of, in aortic 
stenosis, 324 
influence of bony thorax 
on, 262 
areas of, influence of cardiac 
changes on, 264 
of lung on, 262 
of changes in pericar- 
dium on, 263 
of pleura on, 262 
of soft parts on, 261 
in mitral regurgitation, 

307 
normal conditions modi- 
fying, 260 
outline of, 258 

method of determining, 
258 
in consolidation of lung, 263 
in dilatation of heart, 264 

of left ventricle, 264 
in emphysema, 262 
in hypertrophy of heart, 264 

of left ventricle, 264 
in pericarditis, 263 

with effusion, 356 
in retraction of left lung, 263 
in thickening of pleura, 263 
hypertrophy, 348 

differentiated from adherent 
pericardium, 363 
impulse in myocarditis, 350 
murmurs, 276 

oedema, differentiated from 
renal, 232 



Cardiac sounds in aneurism of 
aorta, 371 
in arterio-sclerosis, 374 

changes in rhythm of, 
275 
in embryocardia, 275 
in cantor or gallop 
rhythm, 275 
in reduplication of 
sounds, 276 
intensity of, changes in, 271 
diminution of, 274 
first sound, 274 
second sound, 275 
increase of, 272 
first sound, 273 
second sound, 273 
modifications of, 271 
in myocarditis, 351 
normal, characteristics of, 

267 
in pericarditis with effusion, 

360 
in pneumopericardium, 364 
weakness, irregularity of pulse 
in, 249 
Cardio-pulmonary sounds, 300 
Cardio-respiratory murmurs, dif- 
ferentiated from mitial regur- 
gitation, 312 
Cartilage, en si form, 19 

xiphoid, 19 
Catarrh, pulmonary, 161 
Catarrhal pneumonia, dissemi- 
nated, 161 
Cavernous breathing, 112 
resonance, 137 
I Chest, alar, 41 

barrel-shaped, 40 
bilateral enlargement of, 41 
emphysematous, 40 
normal, description of, 38 
physiological departures 

from, 39 
paralytic, 41 
pathological, 40 

local bulgings of, 49 

depressions or retractions 
of, 50 
phthisical, 41 
pigeon breasted, 44 
pterygoid, 41 



438 



1XDEX. 



Chest, rachitic types of, 43 

unilateral diminution in size 
of, 48 
enlargements of, causes of, 
46 
Cheyne-Stokes breathing, 57 
Chlorosis, arterial pulsations in, 
230 
venous pulsation in, 231 
Circulatory system, auscultation 
of, 266 
fluoroscopic examination of, 

431 
palpation of, 233 
percussion of, 256 
Circumscribed aneurism of aorta, 

365 
Cirrhosis of lung, 174 
Cog-wheel breathing, 109 
Coin resonance, 138 
Congestion of lung, 138 
Consumption. See Pulmonary 

Tuberculosis 
Corrigan's pulse, 332 
Cough, auscultation of, 137 
Crepitations, 116 
dry, 120 
moist, 121 
Cyanosis in obstruction of pul- 
monary artery, 339 
Cylindrical aneurism of aorta, 

365 
Cysts of pancreas, 391 



Depressions, local, of chest, 

causes of, 50 
Diaphragm, 17 

Diastolic murmurs, rhythm of, 

280 
Dilatation, cardiac, 348 

physical signs of, 349 
Drummond's sign in aneurism of 

aorta, 371 
Dry pericarditis, 352 
Dynamic murmurs, 278 
Dysphagia in aneurism of aorta, 

369 
Dyspnoea, expiratory, 143 

inspiratory, 143 



Ellis, curved line of, 213 

Emphysema, 178 
cardiac dullness in, 262 
flatness in, 262 
condition of lung in, 179 
differential diagnosis of, 185 
differentiated from cardiac dys- 
pnoea, 186 
from hydro-pneumo thorax, 

185 
from pneumo-thorax, 185 
effects of, 179 
physical signs of, 180 
pulmonary, 41 
types of, 178 
varieties of, 178 

Emphysematous chest, 40 

Endocardial murmurs. See Mur- 
murs, Cardiac 

Endocarditis, acute, differentiated 
from pericarditis, 361 

Ensiform cartilage, 19 

Epigastric fossa, 19 

Exocardial murmurs, 297 



F.ecal impaction, 408 
Fibrinous pericarditis, 352 
Fibroid phthisis, 174 
Flint murmur, differentiated 

from mitral stenosis, 320 
Florid phthisis. See Pulmonary 

Tuberculosis, Acute 
Fluoroscopic examinations, 425. 
See also X ray 
of adhesive pericarditis, 432 
of aneurism, 432 
of circulatory system, 431 
of hypertrophy and dilata- 
tion of the heart, 432 
of mitral stenosis, 432 
of pericarditis with effusion, 
431 
picture, conditions causingdark 
areas in, 429 
effect of calcareous deposits 
on, 430 
changes in lung on, 428 
fibroid changes on, 429 



INDEX. 



1:39 



Fluoroscopic picture of normal 
thorax, 128 

pleural effusion in. 430 
Fremitus friction, 67 
splashing or succussion, 68 
vocal, causes of, 60. See also 

Vocal Fremitus 
Friction, fremitus, 67 

in pericarditis, 356 
sounds, 120 

creaking, 121 

dry, 120 

grating 121 

grazing, 121 

leathery, 121 

moist, 121 

in pericarditis, 359 

pleuro-pericardial, 300 

rasping, 121 

rubbing, 121 
Functional murmurs, 278 
Fundus, 34 
Fusiform aneurism of aorta, 365 



Gall bladder, enlargements of, 
398 
causes of, 398 
characteristics of, 398 
palpation of, 398 
tumors of, 398 
differential diagnosis of, 
399 
Galloping consumption. See 
Pulmonary Tuberculosis, Acute 
Gaseous pulse, 253 
Gerhardt's change of sound in 

percussion, 86 
Grave's disease, arterial pulsa- 
tions in, 230 
Gurgles, 119 

H 

H.emic murmurs. See Anaemic 
.Murmurs, differentiated from 
aortic stenosis, 327 

Half-moon space, 412 

Harrison furrow, 44 

Harsh breathing, 111 



| Heart, apex of, 29 
auricles of, 30 
auscultation of, 266 
cavities of, 29 

dilatation of, differentiated 
from pericarditis with ef- 
fusion, 362 
diseases of, diagnosis of, 301 
effect of pleurisy on, 210 
hypertrophy of, differentiated 
from pericarditis with ef- 
fusion, 362 
influence of changes in, on 
apex beat, 227 
on percussion sound, 90 
palpation of, 233 
percussion of, 256 
reginal anatomy of, 29 
surface markings of, 30 
Hemorrhagic infarction differen- 
tiated from lobar pneu- 
monia, 173 
pericarditis, 353 
Hinted or indistinct bronchial 

breathing, 111 
Hodgkin's disease, liver in, 395 

spleen in, 402 
Hydatid cysts of liver, 397 

of pleura, 217 
Hydro-pneumo-thorax, 219 
differentiated from emphysema, 

185 
physical signs of, 219 
Hydro-thorax, 41, 218 

physical signs of, 218 
Hypertrophic cirrhosis, liver in, 

395 
Hypertrophy cardiac, 348 
physical signs of, 349 
Hypochondrium, left, percussion 
of, 411 
right, percussion of, 414 
Hysterical breathing, differen- 
tiated from asthma, 191 



Indeterminate breathing, 111 
Infarction of spleen, 402 
Infraclavicular fossae, 19 
Infrascapula region, 20 



440 



INDEX. 



Inspection of abdominal organs, 
375 
technique of, 375 
of the circulatory system, 221 
of the heart, 221 

technique of, 221 
of lungs. 37 
of thorax, 37 
technique of, 37 
Interlobular emphysema, 178 
Interrupted breathing, 109 
Interstitial emphysema, 178 
Intestines, cancer of, 408 
intussusception of, 408 
palpation of, 407 
tumors of, 407 

percussion over, 420 
Intussusception of intestines, 408 



Jerky breathing, 109 

K 

Kidneys, enlargements of, 404 

movable, 403 

palpation of, 403 

regional anatomy of, 35 

tumors of, 404 

differential diagnosis of, 406 
differentiated by percussion 
from those of spleen, 420 
percussion over, 4:20 

wandering, 404 



Laryngeal breath sounds, 98 

stenosis, differentiated from 
asthma, 190 
Larynx, influence of, on breath 

sounds, 124 
Leukaemia, liver in, 395 

spleen in, 402 
Litten's phenomenon, 55 
Liver, abscess of, 396 

cancer of, 396 

congestion of, 394 

degeneration of, 395 

displacement of, 393 
causes of, 393 

enlargements of, differential 
diagnosis of, 397 



Liver, enlargements of, irregular, 
394 
percussion over, 420 
uniform, 394 
fatty, 395 

flatness of, conditions modify- 
ing, 416 
in Hodgkin's disease, 395 
hydatid cysts of, 397 
in hypertrophic cirrhosis, 395 
influence of, on percussion 

sound, 90 
in leukaemia, 395 
obstructive disease of, 397 
palpation of, 392 

facts to be noted on, 393 
percussion of, 415 
in pernicious anaemia, 375 
pulsation of, in tricuspid 

regurgitation, 347 
regional anatomv of, 33 
syphilis of, 396 
tumors of, 394 
Lobular pneumonia, 161 
Ludovici, angle of, 19 
Lung, acute congestion of, 158 
causes of, 158 
physical signs of, 159 
anatomy of, 24 
auscultation of, 96 
borders of, 25 
cirrhosis of, 174 
collapse of, differentiated from 

lobar pneumonia, 174 
consolidation of, cardiac dull- 
ness in, 263 
flatness in, 263 
effect of pleurisy on, 210 
fissures of, 26 
influence of changes in, on 

apex beat, 226 
inspection of, 37 
lobes of, 24 

malignant disease of. 208 
physical signs of. 208 
palpation of, 58 
possive congestion of, 159 
causes of, 159 
physical signs of, 160 
percussion of, 69 
outlines of, 92 
syphilis of, 207 



INDEX. 



441 



M 

MoBurney's point. 408 

Malaria, spleen in, 402 
Mediastinal tumors,differentiated 

from aneurism of aorta, 373 
Mediastinum, influence of 

changes in on apex beat, 229 
Meninges, disease of, irregular j 

pulse due to. 252 
Metallic tinkle. 120, 220 
Mitral obstruction, differentiated 
from tricuspid obstruction, 
344 
orifice, regurgitation at. 302 
presystolic murmurs, 284 
regurgitation, accentuation of 
pulmonic second sound in, 
308 
area of cardiac dullness in, 
307 
flatness in, 307 
diagnosis of pathological 

condition in, 309 
differential diagnosis of, 311 
differentiated from mitral 
stenosis, 319 
from tricuspid regurgita- 
tion, 348 
effects of, 303 

irregularity of pulse in, 249 
location of apex beat in, 305 
murmur of, 307 
physical signs of, 305 
pulse in, 306 
stages of, 303 
thrill in, 306 
stenosis, 312 
causes of, 312 

differential diagnosis of, 319 
effects of, 313 
fluoroscopic examination of, 

432 
irregular pulse due to, 252 
location of apex beat in, 314 
murmur of, 316 
physical signs of, 314 
pulse in, 316 
thrill in 315 
systolic murmurs, 285 
valve, 31 
Movable kidneys, 403 



Mucous clicks, 120 
Murmurs, aortic diastolic, 291 
causes of, 292 
in aortic regurgitation, 333 
Murmur of aortic stenosis, 324 
systolic, 289 
causes of, 289 
arterial, 297 

causes of, 297 
in arterio-sclerosis, 374 
cardiac, 276 

area of diffusion of, 282, 284 
causes of, 276 
characteristics of, 278 
classification of, 277 

inorganic or non-valvular, 

277 
organic or valvular, 277 
conduction of vibrations to 
surface, 283-285, 289, 291, 
294 
intensity of, 279 

changes in, 279 
point of maximum intensity 

of, 282, 284 
quality of, 278 
rhythm of, 280 
time of, method of determin- 
ing, 281 
diastolic, in aneurism of aorta, 

371 
diasystolic, rhythm of, 280 
exocardial, 297 
mitral presystolic, 284 

causes of, 285 
of mitral regurgitation, 307 
stenosis, 316 
systolic, 285 
causes of, 288 
in myocarditis, 351 
in obstruction of pulmonary 

artery, 339 
presystolic, rhythm of, 280 
of pulmonary regurgitation, 

342 
in pulmonic area, 340 
diastolic, 297 

causes of, 297 
systolic, 296 
causes of, 296 
systolic, 297 
rhythm of, 280 



442 



INDEX, 



Murmur, in tricuspid obstruc- 
tion, 344 
presystolic, 293 
causes of, 293 
regurgitation, 347 
systolic, 294 
causes of, 295 
venous, 298 
causes of, 298 
Myocarditis, acute, 349 
forms of, 349 
physical signs of, 349 
chronic, 350 

apex beat in, 350 
cardiac impulse in, 350 

sounds in, 351 
forms of, 350 
murmur in, 351 
physical signs of, 350 
irregular pulse due to, 252 
Myocardium, disease of, 348 

N 

Nervous system, disturbances 
of, irregular pulse due to, 
251 



Obstructive disease of liver, 

397 
(Edema, of lungs. See Pulmo- 
nary (Eedema. 
pulmonary, chronic, differen- 
tiated from acute bronchitis, 
149 
Omentum, palpation of, 387 
tumors of, characteristics of, 
387 
differential diagnosis of, 387 
Ovaries, tumors of, 409 



Palpation of abdominal 
organs, 382 
method of, 382 
of aorta, 240 
of appendix 407 
of blood-vessels, 240 
of the circulatory system, 233 
for fluctuation, 68 
of friction fremitus in, 67 
of gall-bladder, 398 



Palpation of heart, 233 
of intestines. 407 
of kidneys, 403 
of liver/ 'Mvi 
of lung, 58 
method of counting ribs in, 

59 
of omentum, 387 
for pain, 68 
of pancreas, 390 
of pelvic organs. 409 
of peritoneum, 384 
respiratory movements in. 59 
of rhonchi and palpable rales, 

67 
of splashing or succussion 

fremitus, 68 
of spleen, 400 
of stomach, 388 
technique of, 58, 233 
of thorax, 58 
value of, 58, 233 
vibratory phenomena in, 60 
Pancreas, cancer of, 390 

differential diagnosis of, 
391 
cysts of, 391 

differential diagnosis of, 
392 
palpation of. 390 
tumors of. 390 
Paralytic chest, 41 
Patent ductus anteriosus differ- 
entiated from aortic 
stenosis, 327 
from pulmonary ob- 
struction, 341 
Pectoriloquy, 136 
Pelvic organs, palpation of, 409 

tumors of. 409 
Percussion over, 420 
Percussion of abdomen, 411 
of abdominal organs, 411 
ausculatory, 94 
of the circulating system. 256 
fluid in abdominal cavitv in, 

418 
of the heart, 256 
of left hypochondrium, 411 
of liver, 415 
of lung, 69 
methods of, 72. 256 



INDEX. 



44.3 



Percussion, methods of, imme- 
diate or direct, 72 
mediate or indirect. 72 
technique of, 73 
out line- of Lung, ^2 
over abdominal tumors, 420 
over enlargements of liver, 420 

of spleen. 420 
over faecal accumulations. 420 
over tumors of intestines, 420 
of kidney. 420 
of pelvic organs. 420 
of stomach. 420 
of the pmecordia. 256 

areas of, 250 
in pneumopericardium. 364 
of right hypochondrium. 414 
sound, conditions modifying. 
7S 
cracked-pot sound in, 87 
duration of. 71 
elements of. 69 
Friedrich's respiratory 

change of sound. 87 
Gerhardt's change of sound 

in, 86 
individual and regional 

variations of. 90 
influence of the bonv thorax 
on. 80 
of change in air spaces 
on, 85 

in amount of pulmo- 
nary tissue on, 84 
of tension on, 83 
of heart on, 90 
of liver on. 90 
of the pieura on. 81 
of pulmonary consolida- 
tion on. 87 
tissue on, 82 
of the soft parts on. 78 
intensity of. 69 
modified by site of consoli- 
dation.. 89 
pitch of, 70 
quality of. 69 
Wintrich's change of sound 

in. 86 
of splenic area. 413 
stethoscopic. 04 
of stomach, 417 



Percussion of t horax, 69 

of true abdomen, 417 
Pericardial friction sound dif- 
ferent iated from mi- 
tral regurgitation, 

312 
from mitral stenosis, 
320 
Pericarditis. 352 

adhesive, fluoroscopic exami- 
nation of. 432 
cardiac dullness in. 263 

flatness in. 263 
differential diagnosis of. 361 
dry, 352 

friction fremitus in. 356 
sound in, 359 
fibrinous. 352 

friction fremitus in, 356 
sound in. 359 
forms of, 352 
hemorrhagic. 353 
physical signs of, 354 
plastic, 352 

friction fremitus in, 356, 
357 
sound in, 359 
purulent, 353 
sero-fibrinous, 353 
with adhesions. 353 
with effusion, 353 

pegophony in, 360 
bronchial breathing in, 

360 
cardiac dullness in, 357 
flatness in, 357 
impulse in, 356 
sounds in. 360 
differential diagnosis of, 

362 
fluoroscopic examination 

of, 431 
location of apex beat in. 

354 
pulmonary resonance in, 

358 
respiratory sounds in, 

360 
Skoda's resonance in. 358 
Pericardium, diseases of, diag- 
nosis of, 352 



444 



INDEX. 



Pericardium, influence of changes 
in, on apex beat, *2*J7 
regional anatomy of, 32 
sounds made in. 299 
characteristics of, 299 
diagnostic features of, 300 
Peritoneum, palpation of, 384 
Peritonitis, general, abdominal 

Avails in. 385 
Peri-typhlitic abscess, 408 
Phthisical chest. 41 

causes of deformity, 43 
Phthisis. See Pulmonary Tuber- 
culosis, 
acute. See Pulmonary Tuber- 
culosis, Acute, 
catarrhal. See Pulmonary 
Tuberculosis, Acute, 
fibroid, 174 

pneumonic. See Pulmon- 
ary Tuberculosis. Acute, 
tubercular pneumonic. See 
Pulmonary Tuberculosis, 
Acute. 
Pigeon-breasted chest. 44 
Plastic pericarditis. 352 
Pleura, anatomy of, 28 
hydatid of, 217 
influence of change in on 
apex beat, 236 
in on breath sounds, ! 
139 
of diseases of, on apex beat. 
225 
on percussion sounds. SI j 
left, effusions into, differ- 
entiated from pericarditis 
with effusion, 363 
surface markings of, 28 
thickening of, cardiac dull- 
ness in. 263 
flatness in, 263 
Pleurisy, 20j 

condition of sac in, 209 
differential diagnosis of, 

217 
physical signs of, 211 
effect of, on heart, 210 

on lung, 210 
forms of, 209 
with adhesion, 211 

physical signs of, 212 



Pleurisy, with effusion, 41 

condition of sac in, 210 
differentiated from lobar 

pneumonia, 172 
physical signs of, 212 
Pleuritic friction differentiated 
from pericarditis, 362 
sounds, differentiated from 
mitral regurgitation, 312 
Pleurodynia, 217 
Pleuro-pericardial friction, dif- 
ferentiated from pericar- 
ditis. 362 
friction sounds, 300 
Pneumonia, chronic interstitial, 
174 
causes of, 175 
condition of lungs in, 174 
differential diagnosis of, 

178 
physical signs of, 176 
types of, 175 
differentiated from pleurisy, 

218 
lobar, 164 

condition of lungs in. 164 
differential diagnosis of, 

172 
differentiated from acuta 
pulmonary congestion, 
172 
from collapse of lung, 

174 
from hemorrhagic infarc- 
tion, 173 
from pleurisy with effu- 
sion, 172 
physical signs of, 166 
stages of, 164 

engorgement, 164 
gray hepatization or 

resolution, 165 
red hepatization or 
consolidation. 164 
terminations of, 165 
lobular, 161 
causes of, 162 
condition of lung in, 161 
confluent. 162 

differential diagnosis of, 
163 



INDEX. 



445 



Pneumonia, lobular, differenti- 
ated from acute dis- 
seminated tuberculosis, 
163 
from lobar pneumonia, 

164 
from pulmonary collapse, 
163 
disseminated, 162 
physical signs of, 162 
varieties of. 162 
Pneumo-pericardium, 364 
apex beat in, 364 
cardiac sounds in, 364 
percussion in, 364 
physical signs, of, 364 
water-wheel sounds in, 364 
Pneumothorax, 219 

differentiated from emphy- 
sema, 185 
physical signs of, 219 
Praecordia, inspection of, 223 
bulging of, causes of, 2zi5 
percussion of, 256 
Pre-svstolic murmurs, rhythm 

of, 280 
Pterygoid chest, 41 
Puerile breathing, 130 
Pulmonary artery, 30 
obstruction of 337 
causes of, 337 
cyanosis in, 339 
differential diagnosis of, 

341 
effects of, 338 
murmurs in, 339 
physical signs in, 339 
thrill in, 339 
catarrh, 161 
congestion differentiated from 

lobar pneumonia, 172 
emphysema, 41 
obstruction differentiated 

from aortic stenosis, 327 
oedema, 160 
causes of, 160 
physical signs of, 161 
regurgitation, 341 
apex beat in, 342 
causes of. 341 

differential diagnosis of, 
342 



Pulmonary regurgitation, effects 
of, 342 
murmur of, 342 
physical signs of, 342 

resonance in pericarditis, 358 
tissue, influence of, on percus- 
sion sounds, 82 
tuberculosis, acute, 193 

differential diagnosis of, 

195 
physical signs of, 194 
types of, 193 
causes of, 191 
chronic, 197 

condition of lung in, 197 
physical signs of, 200 
stages of, 200 
effect of, on lung, 192 
forms of, 192 
secondary changes of, 192 
site and progress of, 198 
valve, 31 
Pulmonic diastolic murmurs, 297 
obstruction differentiated 

from triscuspid regurgita- 
tion, 348 
sound, accentuation of, 274 
systolic murmurs, 296 
Pulse, 241 

in aneurism of aorta, 369 
in aortic regurgitation, 332 

stenosis, 323 
in conditions of, modifying 
elasticity of arter- 
ies, 252 
resistance in arteries 
and capillaries, 252 
dicrotism of, 253 
elements of, 242 
examination of, 241 
force of, 248 

diminution of, causes of, 

249 
increase, in, causes of, 248 
irregularity in, 249 
frequency of, 244 
intermittent, causes of. 250 

characteristics of, 249 
irregular, causes of. 251 
characteristics of. 250 
due to reflex irritation. 251 
in mitral regurgitation, 306 



4:46 



INDEX, 



Pulse in initial stenosis, 316 
normal, 243 

rapid, causes of. 244 
slow, causes of, 247 
tension of, high, causes of, 
255 
low, causes of. 253 
in tricuspid obstruction, 344 

Pupil, contraction of. in aneur- 
ism of aorta. 307 

Purulent pericarditis. 353 

Pylorus, 34 



Rachitic chest, causes of, 44 

rosary. 44 
Radiograph in cardiac diseases, 

432 
Rales, crepitant. 116 

diagnostic significance of. 

116 
mode of production of. 116 
dry. 127 

cause of. 112 
differentiation of pleural 
from bronchial. 121 
of small moist from crepi- 
tant. 118 
friction. 120 
dry. 120 
moist. 121 
indeterminate or indefinite, 

122 
moist. 128 

characteristics of. 115 
classification of. 117 
importance of size of, 117 
large. 115 
medium. 115 
quality of sound of, 118 
small, 115 
sibilant. 114 
sonorous. 114 
stridor. 114 
Regional anatomy, 17 
Regurgitation at aortic orifice, 
" 327 

at mitral orifice, 302 
causes of. 302 
at pulmonic orifice. 341 
Respiratory moA'ements. 51 



Respiratory movements, abnor- 
mal, alteration in fre- 
quency in. 5Q 
diminished, causes of. 54 
increased, causes of, 54 
costal breathing in, 

causes of. 53 
inferior costal dia- 
phragmatic breath- 
ing in. causes of. 53 
inferior costal in adult 

male. 52 
normal. 52 

alteration in frequency 
in. 5Q 
in rhythm in. 5C) 
costal in women, 52 
dia phragma t i c abdom i- 
nal in children. 52 
murmurs. See Breath Sounds, 
rhythm of. in adult, 57 
in aged. 57 
alteration in. 06 
sounds in pericarditis with 
effusion. 360 
types of. 107 
Rhonchi and palpable rales, 

palpation of. 67 
Rot civs sign. 358 
Rude respiration, 111 



in aneurism of 



Sacciform aneurism of aorta, 

365 
Sanson's signs 

aorta. 371 
Scrobiculus cordis. 19 
Sero-fibrinous pericarditis. 353 
Skoda 's resonance. 215. 358 
Splashing fremitus. 68 
Spleen, abscess of. 402 

enlargements of. 401 
causes of. 401 
percussion over. 401 

in Hodgkiirs disease, 402 

infarction of. 402 

in leukoemia. 402 

in malaria. 402 

palpation of. 400 

percussion of. 413 

regional anatomv of, 34 

syphilis of, 402 * 



INDEX. 



447 



Spleen, tumors of, characteris- 
tics Of, 401 
differential diagnosis of, 
402 
Stenosis at mitral orifice, 312 
Stethoscope, use o\. in auscul- 
tation. 266 
Stethoscopic percussion, 94 
Stomach, dilated, 388 
displaced, 388 
palpation of, 388 
percussion of, 417 
regional anatomy of, 33 
surface markings of, 34 
tenderness over, 388 
tumors of. 389 

characteristic features of, 

390 
percussion over, 420 
Sub-diaphragmatic abscess, dif- 
ferentiated from pleurisy, 
218 
Subtubular breathing. 111 
Succession fremitus, 08 

sound, 120 
Supraclavicular fossa?, 19 
Syphilis of liver, 396 
'of lung. 207 

differential diagnoss of, 

208 
varieties of, 207 
of spleen, 402 
Svstolic murmurs, rhythm of, 
"280 



Thoracic aorta, aneurism of, 
229 

walls, influence of on breath 
sound, 140 
Thorax, anatomy of. 18 

auscultation of, 96 

bony, influence of, on percus- 
sion sounds, 80 

contents of, 21 

inspection of, 37 

palpation of, 58 

percussion of. 69 

subcostal angle of, 20 

surface markings of, 19 
Thrill in aneurism of aorta, 368 

in aortic stenosis, 323 



Thrill in mitral regurgitation, 
306 

stenosis, 315 

in obstruction of pulmonary 

artery, 339 
in tricuspid obstruction, 344 
Thrills, 238 
causes of, 238 
character of, 239 
Trachea, position of, 21 
Tracheal stenosis, differentiated 
from asthma, 190 
tugging, 240 

in aneurism of aorta, 369 
method of examining for, 
240 
Transition breathing, 111 
Tricuspid obstruction, 343 

differential diagnosis of, 

344 
effects of, 343 
murmur in, 344 
physical signs of, 343 
pulse in, 344 
thrill in, 344 
veins in, 343 
pre-systolic murmurs, 293 
regurgitation, 345 
causes of, 345 
differential diagnosis of, 347 
differentiated from mitral 

stenosis, 319 
enect of, 346 
location of apex beat in, 

'346 
murmurs in, 347 
physical signs of, 346 
pulsation of liver in, 347 
stenosis differentiated from 

mitral stenosis, 320 
svstolic murmurs, 294 
valve. 31 
Tubercular pneumonic phthisis. 
See Pulmonary Tuberculosis, 
Acute. 
Tuberculosis, acute diffuse pul- 
monary, differentiated from 
acute bronchitis, 148 . 
pulmonary, differentiated 

from bronchiectasis, 156 
Tumors of abdominal Avails, 
palpation of, 383 



4:48 



INDEX. 



Tumors of kidneys, palpation 

of, 404 
of liver, palpation of. 394 

mediastinal. differentiated 
from aneurism of aorta, 
373 
of omentum, palpation of,387 
of ovaries, 409 

of spleen, differential diag- 
nosis of, 402 
palpation of. 401 
of stomach, palpation of, 3S9 
of uterus. 409 
Typhlitis. 40S 

u 

Ulcerative tuberculosis, 
chronic. See Pulmonary Tu- 
berculosis. Chronic. 
Unilateral diminution in size of 
chest. 48 
enlargements of chest, causes 
of, 46 
Uterus, auscultation of, 424 
tumors of. 409 



Valve areas. 269 
aortic. 271 
mitral, 270 
pulmonic, 271 
tricuspid, 271 

Valves, regional anatomy of, 31 

Valvular disease, chronic, dif- 
ferentiated from pericar- 
ditis, 361 
lesions. 301 

Veiled puff. 138 

Veins, superficial, in aneurism 
of aorta. 367 
in tricuspid obstruction, 343 

Venous murmurs, 298 
pulsation, 231 
abnormal, 231 
in anaemia. 231 
in chlorosis, 231 
normal. 231 



Ventricle, left. 29 
right, 29 

Vocal fremitus, causes of, 00 
in child. 61 

diminished, by changes in 
bronchi. Qo 
in the chest Avail, 67 
in pleura. G6 
in pulmonary tissue, 

increase of, cause of, 64 

in children. 65 

by pulmonary consolida- 
tions. 65 

by tension of pulmonary 
tissue, 6o 

over cavities, 65 
in man, 61 

modified by chest wall, 63 
normal variation in, 61 
over the apices, 62 
physiological increase of on 

right side. 62 
regional variations in, 61 

causes of. 61 
technique of. 61, 64 
in woman, 61 
resonance, characteristics of. 

134 
conditions modifying. 134 
whispered voice or whis- 
pered resonance, 134 

w 

Wandering kidneys, 404 
Water-hammer pulse. 333 
Water-wheel sound in pneumo- 
pericardium, 364 
Wavy breathing, 109 
Wint rich's change of sound in 
percussion, 86 



Xiphoid cartilage. 19 
X-ray examinations. 425 

apparatus for, 425 

value of. 427 



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CLASSIFIED INDEX. 

ANATOMY. Gray, Treves, Gerrish, Rockwell, Woolsey, Huntington. 
BACTERIOLOGY. Abbott, Vaughan & Novy, Senn's (Surgical), Park, 

Zapffe. 
CHEMISTRY. Simon, Att field, Martin & Rockwell, Remsen. 
CLIMATOLOGY. Solly, Hayem & Hare. 

DENTISTRY. Essig (Prosthetic), Kirk (Operative), American System, Cole- 
man, Burchard, Essig Metallurgy. 
DERMATOLOGY. Hyde, Jackson, Pye-Smith, Morris, Jamieson, Harda- 

way, Grin don. 
DIAGNOSIS. Musser, Hare, Simon, Herrick, Collins, Le Fevre. 
DICTIONARIES. Dunglison, Duane, National, Hoblyn, Billings. 
DISPENSATORY. National. 

FRACTURES and DISLOCATIONS . Stimson, Pick. 
GYNECOLOGY. American System, Thomas & Munde, Emmet, Davenport, 

May, Dudley, Crockett, Findley. 
HISTOLOGY. Klein, Schafer, Dunham, Nichols & Vale, Szymonowicz. 
HYGIENE. Egbert, Richardson, Harrington. 

LARYNGOLOGY and RHINOLOGY. Coakley, Posey & Wright, Grayson. 
MATERIA 3IEDICA. Culbreth, Maisch, Farquharson, Bruce, Schleif. 
3IEDICAL JURISPRUDENCE. Taylor. 
MENTAL DISEASES. Clouston, Folsom, Potts, Dercum. 
NERVOUS DISEASES. Dercum, Potts. 
OBSTETRICS. American System, Davis, Parvin, Playfair, King, Jewett, 

Evans, Reynolds & Newell. 
OPHTHALMOLOGY, Norris & Oliver, Nettleship, Ballenger & Wippen, 

Posey & Wright. 
OTOLOGY. Politzer, Burnett, Field, Bacon, Posey & Wright, Grayson. 
PATHOLOGY. Green, Ewing, Coates, Nichols & Vale, Schmaus. 
PEDIATRICS. Smith, Thomson, Williams, Tuttle, Koplik. 
PHARMACOLOGY". Cushny, Culbreth, Hermann. 
PHARMACY. Caspari. 
PHYSICS. Draper, Martin & Rockwell. 

PHYSIOLOGY. Foster, Chapman, Collins & Rockwell, Hall. 
PRACTICE. Flint, Loomis & Thompson, Malsbary, Thompson. 
QUIZ SERIES, POCKET TEXT-BOOKS, MANUALS, EPITOMES, etc. 
SEXUAL DISORDERS. Fuller, Taylor. 
SURGERY". Park, Dennis, Roberts, Ashhurst, Treves, Cheyne & Burghard, 

Gallaudet. 
SURGERY— MINOR. Wharton. 

SURGERY— OPERATIVE. Stimson, Smith, Treves. 
SURGERY— ORTHOPEDIC. Young, Whitman. 
THERAPEUTICS. Hare, Fothergill, Whitla, Hayem & Hare, Bruce, Schleif, 

Cushny, Tirard. 
URINARY DISEASES . Roberts, Black, Taylor. 
VENEREAL DISEASES. Taylor, Hayden, Cornil. 
8.1.02 



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Surgeon. 



Well written and up to date. It 

is a manual admirably adapted to 

teach the beginner the essentials of 

physiology, and to acquaint the 

CONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS- 
EASES OF CHILDREN. Sixth edition, revised and enlarged. In 
one large 8vo. volume of 719 pages. Cloth, $5.25 ; leather, $6.25. 

CORNEL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNO- 
SIS AND TREATMENT. Translated, with Notes and Additions, by 
J. Henry C. Simes, M.D. and J. William White, M. D. In one 
8vo. volume of 461 pages, with 84 illustrations. Cloth, $3.75. 

CROCKETT (M. A.). A POCKET TEXT-BOOK OF DISEASES 
OF WOMEN. In one handsome 12mo. volume of 368 pages, with 
107 illustrations. Cloth, $1.50, net; flexible leather, $2.00, net. 
Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, 
M. D. See page 17. 



This is, like all the other manuals 
in this series, a most excellent guide 
or students and a handy reference 



book for practitioners. — St. Louu 
Medical and Surgical Journal. 



Lea Brothers & Co., Philadelphia and New York. 7 

CROOK (JAMES K.) ON MINERAL WATERS OF THE 
UNITED STATES. Octavo, 575 pages. Cloth, $3.50, net. 
In such a book as this the medical of every water of any known medici- 
profession will find a wonderful ally; nal properties. — The Louisville 
it is remarkably complete in every Monthly Journal. 
detail, giving the results of analyses 

CULBRETH (DAVID M. R.). MATERIA MEDICA AND PHAR- 
MACOLOGY. Second edition. In one handsome octavo volume 
of 881 pages, with 464 illustrations. Cloth, $4.50, net. 

CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. 

Second edition. Handsome 8vo., 732 pp., with 47 illus. Cloth, $3.75, net. 
The best exposition of our knowl- acquainting themselves with the very 
edge of pharmacology which has yet latest knowledge on this very im- 
been given to the medical public, portant subject. — The Montreal Med- 
We can cordially recommend it to ical Journal. 
all our readers who are desirous of 

DALTON(JOHNC). A TREATISE ON HUMAN PHYSIOLOGY. 

Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, 
$5 ; leather, $6. 

DOCTRINES OF THE CIRCULATION OF THE BLOOD. In 

one handsome 12mo. volume of 293 pages. Cloth, $2. 

DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of 
Gynecology. For the use of Students and Practitioners. Fourth 
edition. In one handsome 12mo. volume of 402 pages, with 154 
illustrations. Cloth, $1.75, net. 
Dr. Davenport has the happy j knowing, and presents these princi- 
faculty of selecting just those points j pies in a clear, concise and thorough 
in gynecological therapeutics and I manner. The book can be highly 
surgery which the student and junior commended. — The Medical Age. 
practitioner most stand in need of 

DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR 

STUDENTS AND PRACTITIONERS-. In one very handsome 

octavo volume of 546 pages, with 217 engravings and 30 full-page 

plates in colors and monochrome. Cloth, $5 ; leather, $6. 

From a practical standpoint the thoroughly scientific and brilliant 

work is all that could be desired. A treatise on obstetrics. —3fed. News. 

DAVIS (F. EL). LECTURES ON CLINICAL MEDICINE. Second 
edition. In one 12mo. volume of 287 pages. Cloth, $1.75. 

DE L.A BECHE'S GEOLOGICAL OBSERVER. In one large octavo 
volume of 700 pages, with 300 engravings. Cloth, $4. 

DENNIS (FREDERIC S.) AND BELL.INGS (JOHN S.). A SYS- 
TEM OF SURGERY. In contributions by American Authors. 
Complete work in four very handsome octavo volumes, containing 
3652 pages, with 1585 engravings and 45 full-page plates in colors 
and monochrome. Per volume, cloth, $6.00; leather, $7.00; half 
Morocco, gilt back and top, $8.50. For sale by subscription only. 
Full prospectus free on application to the publishers. 
No work in English can be con- I American Journal of the Medical 

sidered as the rival of this. — The I Sciences. 

DERCUM (FRANCIS X.). A MANUAL OF MENTAL DIS- 
EASES. Octavo, about 350 pages with many engravings. Shortly. 



8 Lea Brothers & Co., Philadelphia and New York. 

DERCUM (FRANCIS X.,) EDITOR. A TEXT-BOOK ON 
NERVOUS DISEASES. By American Authors. In one handsome 
octavo volume of 1054 pages, with 341 engravings and 7 colored 
plates. Cloth, $6.00 ; leather, $7.00. Net. 
The most thoroughly up-to-date The best text-book in any lan- 



treatise that we have on this subject. 
— American Journal of Insanity. 



guage. — The Medical Fortnightly. 



DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. 

Their Classification, History, Symptoms, Pathology and Treatment. 
Very handsome octavo, 240 pages, 46 engravings, and 9 fall-page 
plates in colors. Limited edition, de luxe binding, $4, net. 

DRAPER (JOHNC). MEDICAL PHYSICS. A Text-book for Stu- 
dents and Practitioners of Medicine. In one handsome octavo volume 
of 734 pages, with 376 engravings. Cloth, $4. 

DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. A new American, from the twelfth London 
edition, edited by Stanley Boyd, F. R. C. S. In one large octavo 
volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. 

DUANE (ALEXANDER). A DICTIONARY OF MEDICINE AND 
THE ALLIED SCIENCES. Comprising the Pronunciation, Deriva- 
tion and Full Explanation of Medical, Dental, Pharmaceutical and 
Veterinary Terms. Together with much Collateral Descriptive Mat- 
ter, iNumerous Tables, etc. Third edition. Square octavo of 652 
pages, with 8 colored plates, with thumb index. Cloth, $3.00, net ; 
limp leather, $4.00, net. 

DUDLEY (E. C.). THE PRINCIPLES AND PRACTICE OF 
GYNECOLOGY. Second edition. Handsome octavo of 717 pages, 
with 453 illustrations in black and colors, and 8 colored plates. Cloth, 
$5.00, net; leather, $6.00, net; half Morocco, $6.50, net. 



tice of modern gynecology. — Inter- 
national Medical Magazine. 



The book can be safely recom- 
mended as a complete and reliable 
exposition of the principles and prac- 
DUNGL.ISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- 
ENCE. Containing a full explanation of the various subjects and 
terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- 
macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- 
gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- 
ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. 
By Robley Dunglison, M. D., LL. D., late Professor of Institutes 
of Medicine in the Jefferson Medical College of Philadelphia. Edited 
by Richard J. Dunglison, A. M., M. D. Twenty-second edition, thor- 
oughly revised and greatly enlarged and improved, with the Pronuncia- 
tion, Accentuation and Derivation of the Terms. With Appendix. 
In one magnificent imperial octavo volume of 1350 pages, with thumb 
index. Cloth, $7.00, Net; leather, $8.00, Net. This edition contains 
portrait of Dr. Dunglison. 
The most satisfactory and authori- j scarcely be measured. — Med. Record. 
tative guide to the derivation, defini- ; Pronunciation is indicated by the 
tion and pronunciation of medical phonetic svstem. The definitions are 
terms.— The Charlotte Med. Journal, unusually clear and concise. The 
Covering the entire field of medi- book is wholly satisfactory. — Uni- 
cine, surgery and the collateral versity Medical Magazine. 
sciences, its range of usefulness can 



Lea Brothers & Co., Philadelphia and New York. 9 

DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE 

DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. 
In one octavo volume of 175 pages. Cloth, $1.50. 

DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- 
TOLOGY. Octavo, 450 pages,with 363 illustrations. Cloth, $3.25, net. 
The best one-volume text or refer- 1 of published in America. — Virginia 
ence book on histology that we know I Medical Semi- Monthly. 

NORMAL HISTOLOGY. Second edition. Octavo, 319 pages, 



with 244 illustrations. Cloth, $2.50, net. 

ECKLEY (WILLIAM T.). A GUIDE TO DISSECTION OF THE 
HUMAN BODY. Octavo, about 450 pages, richly illustrated in 
black and colors. In Press. 

REGIONAL ANATOMY OF THE HEAD AND NECK FOR 



STUDENTS AND PRACTITIONERS. Octavo, 240 pages, with 
36 engravings and 20 plates in black and colors. Cloth, $2.50, net. 

EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND 
MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; 
leather, $4.50. 

EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for 
Students and Practitioners. In one handsome 8vo. volume of 576 pages, 
with 148 engravings. Cloth, $3 ; leather, $4. 

EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- 
TATION. Second edition. In one 12mo. volume of 427 pages, 
with 77 illustrations. Cloth, net, $2.25. 



It is written in plain language, 
and, while primarily designed for 
physicians, it can be studied with 
profit by any one of ordinary intel- 



ligence. The writer has adapted it 
to American conditions, and his 
suggestions are, above all, practical. 
— The New York Medical Journal. 



ELLIS (GEORGE VENTER). DEMONSTRATIONS IN ANATOMY. 

Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, 
$4.25 ; leather, $5.25. 

EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- 
TICE OF GYNECOLOGY. Third edition. Octavo, 880 pages, with 
150 original engravings. Cloth, $5 ; leather, $6. 

ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- 
GERY. Eighth edition. In two large octavo volumes containing 
2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. 

ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American 
Text-Books of Dentistry, page 2. 

EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. 

In one handsome 12mo. volume of 409 pages, with 148 illustrations. 
Cloth, $1,75, Net; limp leather, $2.25, net. Lea's Series of Pocket 
Text-books, edited by Bern B. Gallaudet, M.D. See p 17. 

EWING (JAMES) ON THE BLOOD AND ITS DISEASES. Hand- 
some octavo, 423 pages, 28 engravings, 14 colored plates. Cloth, 
net, $3.50. 



10 Lea Brothers & Co., Philadelphia and New York. 

FARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. 

Fourth American from fourth English edition, revised by Frank 
Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. 

FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
EAR. Fourth edition. In one octavo volume of 391 pages, with 73 
engravings and 21 colored plates. Cloth, $3.75. 

FINDLEY (PALMER D.). A TREATISE ON GYNECOLOGI- 
CAL DIAGNOSIS. Octavo, about 600 pages. Amply illustrated. 
Shortly. 

FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND 

PRACTICE OF MEDICINE. Seventh edition, thoroughly revised 

by Frederick P. Henry, M. D. In one large 8vo. volume of 1143 

pages, with engravings. Cloth, $5.00 ; leather, $6.00. 

The work has well earned its lead- ' The best of American text-books 

ing place in medical literature. — on Practice. — Amer. Medico- Surgical 

Medical Record. Bulletin. 

A MANUAL OF AUSCULTATION AND PERCUSSION ; of 

the Physical Diagnosis of Diseases of the Lungs and Heart, and of 
Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. 
In one handsome 12mo. volume of 274 pages, with 12 engravings. 

A PRACTICAL TREATISE ON THE DIAGNOSIS AND 



TREATMENT OF DISEASES OF THE HEART. Second edition 
enlarged. In one octavo volume of 550 pages. Cloth, $4. 

ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. 

A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
Cloth, $3.50. 

FOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. 
ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. 
Cloth, $1.50. With Clouston on Mental Diseases (new edition, see 
page 6) $5.00, net f for the two works. 

FORMULARY, POCKET, see page 32. 

FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. Sixth 

and revised American from the sixth English edition. In one large 

octavo volume of 923 pp., with 257 illus. Cloth, $4.50 ; leather, $5.50. 

Unquestionably the best book that This single volume contains all 

can be placed in the student's hands, that will be necessary in a college 

and as a work of reference for the I course, and all that the physician 

busy physician it can scarcely be will need as well. — Dominion Med. 

excelled. — ThePhila. Polyclinic. \ Monthly. 

FOTHERGILL (J. MILNER). THE PRACTITIONER'S HAND- 
BOOK OF TREATMENT. Third edition. In one handsome octavo 
volume of 664 pages. Cloth, $3.75 ; leather, $4.75. 

FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- 
ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- 
bodying Watts' Physical and Inorganic Chemistry. In one royal 
12mo. volume of 1061 pages, with 168 engravings, and 1 colored 
plate. Cloth, $2.75 ; leather, $3.25. 



Lea Brothers & Co., Philadelphia and New York. 11 



FRANKIjAND (E.) AND JAPP (F. R.). inorganic chemistry. 

In one handsome octavo volume of 677 pages, with 51 engravings and 
2 plates. Cloth, $3.75 ; leather, $4.75. 

FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- 
GANS IN THE MALE. In one very handsome octavo volume of 
238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. 



It is an interesting work, and one 
which is timely and needed. — Medi- 
cal Fortnightly. 

The book is valuable and instruc- 
tive and brings views of sound 



pathology and rational treatment to 
many cases of sexual disturbance 
whose treatment has been too often 
fruitless for good. — Annals of 
Surgery. 



GALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SUR- 
GERY. In one handsome 12mo. volume of about 400 pages, with many 
illustrations. Shortly. Lea's Series of Pocket Text-books, edited by 
Bern B. Gallaudet, M. D. See page 17. 

GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A 
Multum in Parvo. In one square octavo volume of 845 pages, with 
159 engravings. Cloth, $3.75. 

GAYLORD (HARVEY R.) and ASCHOFF (LUDWIG). THE 

PRINCIPLES OF PATHOLOGICAL HISTOLOGY. With an in- 
troductory note by William H. Welch, M. D. In one very hand- 
some quarto volume of 354 pages, with 81 engravings in the text and 
40 full-page plates. Cloth, $7.50, net. 
GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. 
By American Authors. Edited by Frederic H. Gerrish, M. D. In one 
imp. octavo volume of 915 pages, with 950 illustrations in black and 
colors. Cloth, $6.50; flexible waterproof, $7; leather, $7.50, net; 
half Morocco, $8.00, net, 
The illustrations far outnumber j be found in the descriptive text, 
and exceed in size and in profusion ' which is accurate, concise, and gives 
of colors those in any previous work ; the essentials of descriptive anatomy 
and they can well claim to be the with less waste of words and better 
most successful series of anatomical ; emphasis of important points than 
pictures in the world. — The Ameri- any similar text-book with which 
can Practitioner and News. '• we are familiar. — The Boston Medi- 

The chief merit in the book will cal and Surgical Journal. 

GEBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID 
HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. 

GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGI- 
CAL. New fifteenth edition thoroughly revised. In one imperial 
octavo volume of 1249 pages, with 780 large and elaborate engrav- 
ings. Price with illustrations in colors, cloth, $6.25, net ; leather, 
$7.25, net. Price, with illustrations in black, cloth, $5.50; leather, 
$6.50, net. 
This is the best single volume 

upon Anatomy in the English 

language. — University 3fedical Mag- 
azine. 

Holds first place in the esteem of 

both teachers and students. — The 

Brooklyn Medical Journal. 



The most largely used anatomical 
text-book published in the English 
language. — Annals of Surgery. 

Gray's Anatomy affords the student 
more satisfaction than any other 
treatise with which we are familiar. 
— Buffalo Med. Journal. 



12 Lea Brothers & Co., Philadelphia and New York. 

GRAYSON (CHARLES P.). DISEASES OF THE THROAT, 
NOSE, AND ASSOCIATED AFFECTIONS OF THE EAR. In 
one handsome octavo volume of about 500 pages, with 129 engravings 
and 8 plates in colors and monochrome. In Press. 

GOULD (.A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 
vol. of 589 pages. Cloth, $2. See Student 's Series of Manuals, p. 27. 

GREEN (T. HENRY). PATHOLOGY AND MORBID ANATOMY 

Ninth edition. In one handsome octavo volume of 577 pages, with 
339 engravings and 4 colored plates. Cloth, $3.25, net. 

A work that is the text-book of; The work is an essential to the 
probably four-fifths of all the stu- practitioner — whether as surgeon or 
dents of pathology in the United i physician. It is the best of up-to- 
States and Great Britain. — The date text-books. — Virginia Medical 
American Practitioner and News. \ Monthly. 

GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM- 
ISTRY. For the Use of Students. Based upon Bowman's Medical 
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. 

GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- 
EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
BLADDER, THE PROSTATE GLAND AND THE URETHRA. 
Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. 

GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN 
DISEASES. In one handsome 12mo. volume of 350 pages, with 
many illustrations. Shortly. Lea's Series of Pocket Text-books, edited 
by Bern B. Gallaudet, M. D. 

HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN 
Second American from the third English edition. In one octavo vol- 
ume of 554 pages, with 11 engravings. Cloth, $3.50. 

HALL (WINFIELD S.). TEXT-BOOK OF PHYSIOLOGY. Octavo 
of 672 pages, with 343 engravings, and 6 full page colored plates. 
Cloth, $4.00 ; leather, $5.00, net. 

Truly a scientific treatment of the of which needs to be more strongly 
subject. The clearness with which | impressed upon students A book 
physiological facts are demonstrated which makes this so easily possible 
makes it of special value to the I is to be highly commended. — West- 
medical student. The science of i em Medical Review. 
physiology is one, the importance ! 

HAMILTON (ALLAN MCLANE). NERVOUS DISEASES. THEIR 
DESCRIPTION AND TREATMENT. Second and revised edition. 
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 

HARD AW AY (W. A.). MANUAL OF SKIN DISEASES. Second 
edition. In one 12mo. volume of 560 pages, with 40 illustrations and 
2 plates. Cloth, $2.25, net. 
The best of all the small books to j day clinical experience. His great 



recommend to students and practi- 
tioners. Probably no one of our 
dermatologists has had a wider e very- 



strength is in diagnosis, descriptions 
of lesions and especially in treat- 
ment. — Indiana Medical Journal. 



Lka Brothers & Co., Philadelphia and New York. 13 



HARK (HOBART AMORY). PRACTICAL DIAGNOSIS. THE 
USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. Fourth 
edition. In one octavo volume of 623 pages, with 205 engravings 
and 14 full-page colored plates. Cloth, $5.00, net ; half Morocco, 
$6.50, net. 



It is unique in many respects, and 
the author lias introduced radical 
changes which will be welcomed by 
all. Anyone who reads this book 
will become a more acute observer, 
will pay more attention to the simple 
yet indicative signs nf disease, and 



he will become a better diagnosti- 
cian. This is a companion to Prac- 
tical Therapeutics, by the same 
author, and it is difficult to conceive 
of any two works of greater practical 
utility. — Medical Review. 



HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL 

THERAPEUTICS, with Special Reference to the Application of Reme- 
dial Measures to Disease and their Employment upon a Rational 
Basis. With articles on various subjects by well-known specialists. 
Ninth and revised edition. In one octavo volume of 851 pages, 
with 105 engravings and 4 colored plates. Cloth, $4.00, net; leather, 
$5.00, net; half Morocco, $5.50, net. 



Its classifications are inimitable, 
and the readiness with which any- 
thing can be found is the most won- 
derful achievement of the art of in- 
dexing. This edition takes in all 
the latest discovered remedies. — 
The St. Louis Clinique. 

The great value of the work lies 
in the fact that precise indications 
for administration are given. A 
complete index of diseases and 
remedies makes it an easy reference 
work. It has been arranged so that 



it can be readily used in connection 
with Hare's Practical Diagnosis. 
For the needs of the student and 
general practitioner it has no equal. 
— Medical Sentinel. 

The best planned therapeutic work 
of the century. — American Prac- 
titioner and News. 

It is a book precisely adapted to 
the needs of the busy practitioner, 
who can rely upon finding exactly 
what he needs. — The National Med- 
ical Review. 



HARE'S SYSTEM OF PRACTICAL THERAPEUTICS. In a series 
of contributions by eminent practitioners. Second edition. In three 
large octavo volumes containing 2593 pages, with 457 engravings 
and 26 full-page plates. Price per volume, cloth, $5.00; leather, 
$6.00; half morocco, $7.00. Full prospectus free on application. 
For sale by subscription only. 



The Hare's System of ten years 
ago will hardly be recognized in 
this new edition, so complete are the 
changes, so extended the disserta- 
tion and so complete the re-dress. 
The additions alone are sufficient to 
make a new volume. The choice of 
subjects is wide and the names of 
the authors are a sufficient guaran- 
tee of the character of the mode of 
treatment. The dominant feature 
of the work, one that the well- 



known editor constantly presents, is 
the every day workability of treat- 
ments advocated. Here are no 
lengthy theoretical dissertations 
largely padded by quotations from 
European authors, but concise, prac- 
tical rules that can be made to fit 
present-day needs. What, why 
and how are the questions with ref- 
erence to the use of drugs that the 
authors answer — particularly the 
HOW. — Medical Neivs. 



14 Lea Brothebs & Co., Philadelphia and New York. 



HARE (HOBART AMORY) ON THE MEDICAL COMPLICA- 
TIONS AND SEQUELiE OF TYPHOID FEVER. Octavo, 276 
pages, 21 engravings and. two full-page plates. Cloth, $2.40, net. 
A very valuable production. One i read with great profit. — Cleveland 

of the very best products of Dr. Journal of Medicine. 

Hare and one that every man can I 

HARRINGTON (CHARLES). PRACTICAL HYGIENE. Hand- 
some octavo, 721 pages, 105 engravings, 12 plates. JVst, $4.25. 

HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. 
volume, 669 pages, with 144 engravings. Cloth, $2.75 . 

A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 



12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 

A CONSPECTUS OF THE MEDICA.L SCIENCES. Comprising 



Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 
12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25; leather, $5. 

HAYDEN (JAMES R.). A POCKET TEXT-BOOK OF VENER- 
EAL DISEASES. Third edition. In one 12mo. volume of 304 
pages, with 66 engravings. Cloth, $1.75, net. Flexible leather, 
$2.25, net. 



It is practical, concise, definite 
and of sufficient fulness to be satis- 
factory. — Chicago Clinical Review. 



It is well written, up to date, and 
will be found very useful. — Inter- 
national Medical Magazine. 



HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND 

NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- 
tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
of 414 pages,with 113 engravings. Cloth, $3. 



HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. 

one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. 
Student's Series of Manuals, page 27. 



In 



HERMANN (L..). EXPERIMENTAL PHARMACOLOGY. A Hand- 
book of the Methods for Determining the Physiological Actions of 
Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. 
volume of 199 pages, with 32 engravings. Cloth, $1.50. 

HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In 
one handsome 12mo. volume of 429 pages, with 80 engravings and 2 
colored plates. Cloth, $2.50. 



We commend the book not only to 
the undergraduate, but also to the 
physician who desires a ready means 
of refreshing his knowledge of diag- 
nosis in the exigencies of professional 
life. — Memphis Medical Monthly. 



Excellently arranged, practical, 
concise, up-to-date, and eminently 
well fitted for the use of the prac- 
titioner as well as of the student.— 
Chicago Med. Recorder. 



Lea Brothers & Co., Philadelphia and New York. 15 

HERTER (C. A.). LECTURES ON CHEMICAL PATHOLOGY. 

In one 12mo., volume of 454 pages. Cloth, $1.75, net. 

HILL, (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. 

HILLilER (THOMAS). A HANDBOOK OF SKIN DISEASES. 

Second edition. In one royal 12mo. volume of 353 pages, with two 
plates. Cloth, $2.25. 

HIRST (BARTON C.) AND PIERSOL. (GEORGE A.). HUMAN 
MONSTROSITIES. Magnificent folio, containing 220 pages of text 
and illustrated with 123 engravings and 39 large photographic plates 
from nature. In four parts, price each, $5. 

HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS 
USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
Thirteenth edition. In one 12mo. volume of 845 pages. Cloth, 
$3.00, net. 

HODGE (HUGH L..). ON DISEASES PECULIAR TO WOMEN, 
INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. 

HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
Examination of Medicinal Chemicals and their Preparations. Third 
edition, entirely rewritten and much enlarged. In one handsome octavo 
volume of 621 pages, with 179 engravings. Cloth, $4.25. 

HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- 
ciples and Practice. Fifth edition. Edited by T. Pickering Pick, 
F.R.C.S. In one handsome octavo volume of 1008 pages, with 428 en- 
gravings. Cloth, $6 ; leather, $7. 

A SYSTEM OF SURGERY. With notes and additions by various 

American authors. Edited by John H. Packard, M. D. In three 
very handsome 8vo. volumes containing 3137 double-columned pages, 
with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; 
leather, $7 ; half Russia, $7.50. For sale by tubscription only. 

HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one 
octavo volume of 308 pages. Cloth, $2.50. 

HUNTINGTON (GEORGE S.). A TREATISE ON AP>DOMINAL 
ANATOMY. Quarto, with 250 pages of text and 300 full-page 
plates, Shortly. 



16 Lea Brothebs & Co., Philadelphia and New York. 



HYDE (JAMES NEVINS) AND MONTGOMERY (F. H.) A 

PRACTICAL TREATISE ON DISEASES OF THE SKIN. Sixth 
edition, thoroughly revised. Octavo, 832 pages, with 107 engrav- 
ings and 27 full-page plates, 9 of which are colored. Cloth, $4.50, net; 
leather, $5.50, net; half Morocco, $6.00, net. 



This edition has been carefully re- 
vised, and every real advance has 
been recognized. The work answers 
the needs of the general practitioner, 
the specialist, and the student. — The 
Ohio Med. Jour. 

A treatise of exceptional merit 
characterized by conscientious care 
and scientific accuracy. — Buffalo 
Med. Journal. 

A complete exposition of our 
knowledge of cutaneous medicine as 
it exists to-day. The teaching in- 



culcated throughout is sound as well 
as practical. — The American Jour- 
nal of the Medical Sciences. 

It is the best one-volume work 
that we know. — Virginia Medical 
Semi-Monthly. 

A full and thoroughly modern 
text-book on dermatology. — The 
Pittsburg Medical Review. 

The most practical handbook on 
dermatology with which we are ac- 
quainted. — Chicago Medical Re- 
corder. 



JACKSON (GEORGE THOMAS). THE READY-REFERENCE 
HANDBOOK OF DISEASES OF THE SKIN. Fourth edition. 
In one 12mo. volume of 617 pages, with 82 illustrations and 3 colored 
plates. Cloth, $2.75, net. 



As a student's manual, it may be 
considered beyond criticism. The 
book is singularly full. — St. Louis 
Medical and Surgical Journal. 



Without doubt forms one of the 
best guides for the beginner in der- 
matology that is to be found in the 
English language. — Medicine. 



JAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third 
edition. In one octavo volume of 656 pages, with 1 engraving and 9 
double-page chromo-lithographio plates. Cloth, $6. 

JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. Second 
edition. In one 12mo. volume of 385 pages, with 80 engravings and 
5 colored plates. Cloth, $2.25. 



An exceedingly useful manual for I 
student and practitioner. The au- 
thor has succeeded unusually well I 
in condensing the text and in arrang- ] 



ing it in attractive and easily tangi- 
ble form. The book is well illus- 
trated throughout. — Nashville Jour, 
of Medicine and Surgery. 



— THE PRACTICE OF OBSTETRICS. Second edition. By Am- 
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engravings in black and colors, and 35 fall-page colored plates. 
Cloth, $5.00, net; leather, $6.00, net; half Morocco, $6.50, net. 



A clear and practical treatise upon 
obstetrics by well-known teachers of 
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sure to be popular with medical 
students, as well as being of extreme 
value to the practitioner. — The 
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Lea Brothers & Co., Philadelphia and New York. 17 



JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE 
AND PRACTICE. Second edition. In one octavo volume of 549 
pages, with 201 engravings, 17 chromo-lithographic plates, test-types of 
Jaeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, 
$5.50 ; leather, $6.50. 

KING (A. F. A.). A MANUAL OF OBSTETRICS. Eighth edition. 
In one 12mo. volume of 612 pages, with 264 illustrations. Cloth, 
$2.50, net. 



of nearly every fact of importance. 
— Virginia Med. Semi- Monthly. 



From first to finish it is thoroughly 
practical, concise in expression, well 
illustrated, and includes a statement 

KIRK (EDWARD C). OPERATIVE DENTISTRY. Second 
edition. Handsome octavo of 857 pages, with 897 illustrations. See 
American Text-Books of Dentistry, page 2. 



tempted. We can heartily recom- 
mend it to the profession. — The 

Ohio Dental Journal. 



We have only the highest praise 
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in every particular, and surpasses 
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KLEIN (E.). ELEMENTS OF HISTOLOGY. Fifth edition. In 
one 12mo. volume of 506 pages, with 296 engravings. Cloth, $2.00, 
net. See Student's Series of Manuals, page 27. 
It is the most complete and con- \ This work deservedly occupies a 

cise work of the kind that has yet ! first place as a text-book on his- 

emanated from the press. — The Med- \ tology. — Canadian Practitioner. 

ical Age. 

KOPLilK (HENRY). THE DISEASES OF INFANCY AND 

CHILDHOOD. Octavo, about 700 pages with 168 engravings. In 
press. 
L.ANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 

handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 

LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- 
BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. 

LEA'S SERIES OF POCKET TEXT-BOOKS, edited by Bern 
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series of 16 very handsome 12mo. volumes of 350-450 pages each, 
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Collins and Rockwell's Physiology. Martin and Rockwell's Chem- 
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Schleif's Materia Medica, Therapeutics, Medical Latin, etc. Mals- 
bary's Practice of Medicine. Collins' Diagnosis. Potts' Nervous 
and Mental Diseases. Gallaudet's Surgery. Grindon's Der- 
matology. Ballenger and Wippern's Diseases of the Eye, Ear, 
Throat and Nose. Evans' Obstetrics. Crockett's Gynecology. 
Tuttle's Diseases of Children. Rockwell's Anatomy. Zapffe's 
Bacteriology. 

For separate notices see under various authors' names. 

LiEA (HENRY C). A HISTORY OF AURICULAR CONFESSION 
AND INDULGENCES IN THE LATIN CHURCH. In three 
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18 Lea Brothers & Co., Philadelphia and New York. 

LEA (HENRY C). CHAPTERS FROM THE RELIGIOUS HIS- 
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AND ILLUMINATI OF THE ENDEMONIADAS ; EL SANTO 
NlftO DE LA GUARDIA. 12mo., 522 pages. Cloth, $2.50. 

THE MORISCOS OF SPAIN, THEIR CONVERSION AND 

EXPULSION. In one royal 12mo. volume of 425 pages. Cloth, 
$2.25, net. 

SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER 

OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
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STUDIES IN CHURCH HISTORY. The Rise of the Temporal 

Power — Benefit of Clergy — Excommunication. New edition. In one 
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AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 

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LEA'S SERIES OF MEDICAL EPITOMES^ Covering the en- 
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1, Hale's Anatomy. 2, Guenther's Phy*iology. 3, McGlannon's Chemis- 
try and Physics. 4, Kiepe's Materia Medica and Therapeutics. 5. 
Dayton's Practice of Medicine. 6, Hollis's Physical Diagnosis. 7, 
Arneill's Clinical Diagnosis and Urinalysis. 8, Nagle's Nervous and 
Mental Diseases. 9, Wathen's Histology. 10, Stenhouse's Pathology. 
11, Archinard's Bacteriology. 12, Magee and Johnson's Surgery. 13, 
Yeasey's Ophthalmology. 14, Brown and Ferguson's Ear, Nose and 
Throat 15, Schmidt's Genito-Urinary and Venereal Diseases. 16, 
Schalek's Dermatology. 17, Pedersen's Gynaecology. 18, Manton's 
Obstetrics. 19, Tuley's Pediatrics. 20, Dwight's jurisprudence and 
Toxicology. 

LE FEVRE (EGBERT). A TEXT-BOOK OF PHYSICAL DIAG- 
NOSIS. In one 12mo. volume of about 350 pages, amply illustrated. 
In press. 

LONG (ELI H.). A MANUAL OF DENTAL MATERIA MEDICA 
AND THERAPEUTICS. 12mo, about 350 pages with many en- 
gravings. Shortly. 

LOOMIS (ALFRED L.) AND THOMPSON (W. GILMAN, 
EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In 

Contributions by Various American Authors. In four octavo vol- 
umes of about 900 pages each, fully illustrated in black and colors. 
Per volume, cloth, $5 ; leather, $6 ; half Morocco, $7. For sale by 
subscription only. Full prospectus free on application to the Pub- 
lishers. 

LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 

very handsome octavo volume of 925 pages, with 170 engravings. 
Cloth,^$4.75 ; leather, $5.75. 



Lea Brothers & Co., Philadelphia and New York. 19 



LYONS (ROBERT D.). A TREATISE ON FEVER. In one octayo 
volume of 362 pages. Cloth, $2.25. 

MAISCH (JOHN M.). A MANUAL OF ORGANIC MATERIA 
MEDICA. Seventh edition, thoroughly revised by H. C. C. Maisch, 
Ph. G., Ph. D. In one very handsome 12mo. volume of 612 pages, with 
285 engravings. Cloth, $2.50, net. 



Used as text-book in every college 
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and recommended in medical col- 
leges. — American Therapist, 



The best handbook upon phar- 
macognosy of any published in this 
country. — Boston Med. & Sur. Jour. 



MALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF 
THEORY AND PRACTICE OF MEDICINE. In one handsome 
12mo. volume of 405 pages, with 45 illustrations. Cloth, $1.75, net; 
flexible red leather, $2.25, net. Lea's Series of Pocket Text-books, 
edited by Bern B. Gallaudet, M. D. See page 17. 

Will readily commend itself to 
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bringing forward as it does the most 



recent advances in medicine with 
the best of that which is old. — 
Medical Revieiv of Revieius. 



MANUALS. See Student 1 s Quiz Series, page 27, Student's Series of 
Manuals, page 27, Series of Clinical Manuals, page 25, and Series of 
Medical Epitomes, page 18. 

MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. 
volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. 

In one 12mo. volume of about 400 pp., fully illustrated. Preparing. 

MARTIN (W ALTON) AND ROCKWELL (WM. H). A POCKET 
TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand- 
some 12mo. volume of 366 pages, with 137 illustrations. Cloth, $1.50, 
net; limp leather, $2.00, net. Lea's Series of Pocket Text-Books, 
edited by Bern B. Gallaudet, M. D. See page 17. 

ter is excellent. — The Medical and 



The work accurately reflects both 
sciences in their present develop- 
ment. The arrangement of the mat- 



Surgical monitor. 



MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For 
the use of Students and Practitioners. Second edition, revised by L. 
S. Ratj, M. D. In one 12mo. volume of 360 pages, with 31 engrav- 
ings. Cloth, $1.75. 

MEDICAL NEWS POCKET FORMULARY, see page 32. 



20 Lea Brothers & Co., Philadelphia and New York. 



MITCHELL. (S. WEIR). CLINICAL LESSONS ON NERVOUS 
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The book treats of hysteria, recur- 
rent melancholia, disorders of sleep, 
choreic movements, false sensations 
of cold, ataxia, hemiplegic pain, 
treatment of sciatica, erythromelal- 
gia, reflex ocularneurosis, hysteric 



contractions, rotary movements in 
the feeble minded, etc. Few can 
speak with more authority than the 
author. — The Journal of the Ameri- 
can Medical Association. 



MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF 
INJURIES OF NERVES AND THEIR TREATMENT. In 

one handsome 12mo. »volume of 239 pages, with 12 illustrations. 
Cloth, $1.75. 



MORRIS (MALCOLM). DISEASES OF THE SKIN. Second 
edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- 
graphic plates and 26 engravings. Cloth, $3.25, net. 



The work is essentially clinical 
and practical in its scope and is 
characterized throughout by clear- 
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strong common sense. It is alike 
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MULLER (J.). PRINCIPLES OF PHYSICS AND METEOR- 
OLOGY. In one large 8vo. vol. of 623 pages, with 538 cuts. 
Cloth, $4.50. 

MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL 
DIAGNOSIS, for Students and Physicians. Fourth edition, thor- 
oughly revised. In one octavo volume of 1104 pages, with 250 en- 
gravings and 49 full-page colored plates. Cloth, $6.00, net; leather, 
$7.00, net; half Morocco, $7.50, net. 



We have no work of equal value 
in English. — University Medical 
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The best of its kind, invaluable to 
the student, general practitioner and 
teacher. — Montreal Medical Journal. 



NATIONAL DISPENSATORY. See Stille, Maisch dc Caspari, p. 27. 

NATIONAL FORMULARY. See Stille, Maisch & Caspari' s National 
Dispensatory, page 27. 



NATIONAL MEDICAL DICTIONARY. See Billings, page 4. 



Lea Brothers A Co., Philadelphia and New York. 21 



NETTLESHIP (E.). DISEASES OF THE EYE. Sixth edition, 
thoroughly revised. In one 12mo. volume of 562 pages, with 192 
engravings, and 5 colored plates, test-types, formulae and color- 
blindness test. Cloth, $2.25, net. 
By far the best student's text-book l 



on the subject of ophthalmology. — 
The Clinical Review. 

This work for compactness, practi- 
cality and clearness has no superior 
in the English language.— Journal 
of Medicine and Science. 



The present edition is the result 
of revision both in England and 
America, and therefore contains the 
latest and best ophthalmological 
ideas of both continents. — The Phy- 
sician and Surgeon. 



NICHOLS (JOHN B.) AND VALE (F. P.). A POCKET TEXT- 
BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 
12mo. volume of 452 pages, with 213 illustrations. Cloth, $1.75, net : 
flexible red leather, $2.25, net. 

Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, 
M. D. See page 17. 



Systematically arranged, and in 
the highest degree, interesting. 
Thoroughly up to date. The book 



can safely and conscientiously rec- 
ommend it to both students and 
practitioners. — The St. Louis Medi- 



is an exceptionally good one. We i cal and Surgical Journal. 



NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF 
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
engravings and 5 colored plates. Cloth, $5 ; leather, $6. 



It is practical in its teachings. | 
We unreservedly endorse it as the 
best, the safest and the most compre- 
hensive volume upon the subject that 



has ever been offered to the Amer- 
ican medical public. — Annals o/ 
Ophthalmology and Otology. 



OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 

In one 12mo. volume of 525 pages, with 85 engravings and 4 colored 
plates. Cloth, $2. See Series of Clinical Manuals, page 25. 



PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- 
CAN AUTHORS. Third edition. In one royal octavo volume 
of 1408 pages, with 692 engravings and 64 full-page plates. Cloth, 
$7.00, net) leather, $8.00, net. 



The work is fresh, clear and practi- 
cal, covering the ground thoroughly 
yet briefly, and well arranged for 
rapid reference, so that it will be of 
special value to the student and busy 
practitioner. The pathology is 
broad, clear and scientific, while the 
suggestions upon treatment are 



clear-cut, thoroughly modern and 
admirably resourceful. — Johns Hop- 
kins Hospital Bulletin. 

The latest and best work written 
upon the science and art of surgery. 
Columbus Medical Journal. 

It is thoroughly practical and yet 
thoroughly scientific. — Med. News. 



22 Lea Bbothebs & Co., Philadelphia and New York. 

PARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND 

SURGERY. 12mo., 688 pages, with 87 illustrations in black and 
colors, and 2 plates. Cloth, $3.00 net. 

This book fills a very distinct [ of view of the hygienist and public 

health officer. The work is correct 
and very well up to date. — The Mon- 
treal Medical Journal. 



gap. t None of the text-books in our 
language take up the subject of bac- 
teriology so thoroughly and so 
soundly as does this from the point 



PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS 
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- 
MENT. In one octavo volume of 272 pages. Cloth, $2.50. 

PARVIN (THEOPHILUS). THE SCIENCE AND ART OF OB- 
STETRICS. Third edition. In one handsome octavo volume of 
677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; 
leather, $5.25. 

English language. — Medical Fort- 



Parvin's work in practical, con- 
cise and comprehensive. We com- 
mend it as first of its class in the 



nightly. 



PEPPER'S SYSTEM OF MEDICINE. See page 3. 

PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's 
Series of Manuals, page 27. 

SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 



with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 

PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. 

In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND 
PRACTICE OF MIDWIFERY. Seventh American from the ninth 
English edition. In one octavo volume of 700 pages, with 207 
engravings and 7 plates. Cloth, $3.75 net; leather, $4.75, net. 

An epitome of the science and a safe guide to both student and 
practice of midwifery, which em- , obstetrician. It holds a place among 
bodies all recent advances. — The ! the ablest English-speaking authori- 
Medical Fortnightly. I ties on the obstetric art. — Buffalo 

This work must occupy a fore- j Medical and Surgical Journal. 
most place in obstetric medicine as j 

THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- 
TION AND HYSTERIA. In one 12mo. volume of 97 pages 
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Lea Brothers & Co., Philadelphia and New York. 23 



POCKET FORMULARY, see page 32. 

POCKET TEXT-BOOKS, see page 18. 

POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
EAR AND ADJACENT ORGANS. Third American from the 
Fourth German edition. In one octavo volume of 748 pages, with 
330 original engravings. Preparing. 

POTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS 
AND MENTAL DISEASES. In one handsome 12mo. volume of 
445 pages, with 88 engravings. Cloth, $1.75, net; limp leather, $2.25, 
net. Lea's Series of Pocket Text-books, edited by Bern B. Gallatj- 
det, M. D. See page 17. 

Dr. Potts has succeeded in de- of the numerous discoveries in every 
picting the main facts in a manner ; branch of neurology is clearly pre- 
that will be appreciated by students sented. The book is a reliable guide, 
and general practitioners. The gist | — The Medical Bulletin. 

A TEXTBOOK ON MEDICAL AND SURGICAL ELECTRI- 
CITY. Octavo, about 350 pages, amply illustrated. Shortly. 

POSEY (W. C.) AND WRIGHT (JONATHAN). A TREATISE 
ON THE EYE, NOSE, THROAT AND EAR. Octavo, about 1100 
pages, richly illustrated in black and colors. In press. 

PROGRESSIVE MEDICINE, see page 32. 

PURDY (CHARLES W.). BRIGHT'S DISEASE AND ALLIED 
AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 
pages, with 18 engravings. Cloth, $2. 



PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 

12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. 

QUIZ SERIES. See Student's Quiz Series, page 27. 

RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 

12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See 
Student's Series of Manuals, page 27. 

REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEil- 
ISTRY. Fifth edition, thoroughly revised. In one 12mo. vol- 
ume of 326 pages. Cloth, $2. 



A clear and concise explanation 
of a difficult subject. We cordially 
recommend it. — The London Lancet. 

The book is equally adapted to the 



student of chemistry or the practi- 
tioner who desires "to broaden Lin 
theoretical knowledge of chemistry. 
— New Orleans Med. and Surg. Jour. 



24 Lea Brothers & Co., Philadelphia and New York. 

REYNOLDS (EDWARD) AND NEWELL (F. S). MANUAL 
OF PRACTICAL OBSTETRICS. Octavo, about GOO pages, richly 
illustrated. Shortly. 

RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI- 
CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. 

ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF 

MODERN SURGERY. Second edition. In one octavo volume of 
838 pages with 473 engravings and 8 plates. Cloth, $4.25, net; leather, 
$5.25, net. 



A clear, concise, comprehensive 
and practical presentation of the 
most modern surgery. The student 
or practitioner will not find a more 



satisfactory or valuable single vol- 
ume work on this subject. — Pacific 
Medical Journal. 



ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON 
URINARY AND RENAL DISEASES, INCLUDING URINARY 
DEPOSITS. Fourth American from the fourth London edition. In 
one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. 

ROCKWELL, (W. H., Jr.). A POCKET TEXT-BOOK OF AN- 
ATOMY. 12mo., about 450 pages, illustrated. In press. 

ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE 
NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, 
with 184 engravings. Cloth, $4.50 ; leather, $5.50. 

SOHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- 
OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students. 
Sixth edition. In one handsome octavo volume of 426 pages, 
with 463 illustrations. Cloth, $3.00, net. 

Nowhere else will the same very | The most satisfactory elementary 
moderate outlay secure as thoroughly ! text-book of histology in the Eng- 
useful and interesting an atlas of | lish language. — The Boston Med. and 
structural anatomy. — The American \ Sur. Jour. 
Journal of the Medical Sciences. 

-A COURSE OF PRACTICAL HISTOLOGY. Second edition. 



In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. 

SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS, 
PRESCRIPTION WRITING, MEDICAL LATIN, ETC. New (2d) 
edition. Preparing. 12mo., 352 pages. Lea's Series of Pocket 
Text-books. Edited by Bern B. Gallaudet, M. D. See page 17. 

We commend the book for it con- college courses on Materia Medica 

tains in a concise, definite, and as- and Therapeutics. — The National 

similable form the essential knowl- Medical Review. 
edge required in the most complete 



Lea Brothers & Co., Philadelphia and New York. 25 

SOHMAUS (HANS.) AND EWING (JAMES). PATHOLOGY 
AND PATHOLOGICAL ANATOMY. Sixth edition. Octavo, 
about 800 pages, with 320 engravings in black and colors. In press. 

SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- 
tion. In one octavo volume of 268 pages, with 13 plates, 10 of which 
are colored, and 9 engravings. Cloth, $2. 

SERIES OF CLINICAL MANUALS. A Series of Authoritative 
Monographs on Important Clinical Subjects, in 12mo. volumes of about 
550 pages, well illustrated. The following volumes are now ready : 
Yeo on Food in Health and Disease, second edition, $2.50 ; Carter 
and Frost's Ophthalmic Surgery, $2.25 ; Marsh on Diseases of the 
Joints, $2 ; O wen on Surgical Diseases of Children, $2 ; Pick on 
Fractures and Dislocations, $2. 
For separate notices, see under various authors' names. 

SERIES OF STUDENT'S MANUALS. See page 27. 

SERIES OF MEDICAL EPITOMES. See page 18. 

SIMON (CHARLES E.). A TEXT-BOOK ON PHYSIOLOGICAL 

CHEMISTRY. Octavo, 453 pages. Cloth. $3.25, net. 

SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- 
SCOPICAL AND CHEMICAL METHODS. Fourth edition. In 
one octavo volume of 608 pages, with 139 engravings and 19 full-page 
colored plates. Cloth, $3.75, net. 
This book thoroughly deserves its j In all respects entirely up to date. 

success. It is a very complete, authen- I — Medical Record. 

tic and useful manual of the micro- i The chapter on examination or 



the urine is the most complete and 
advanced that we know of in the 
English language. — Canadian Prac- 
titioner. 



scopical and chemical methods 
which are employed in diagnosis. 
Very excellent colored plates illus- 
trate this work. — New York Medical 
Journal. 

SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures 
and Laboratory Work for Beginners in Chemistry. A Text-book 
specially adapted for Students of Pharmacy and Medicine. Seventh 
edition. In one 8vo. volume of 613 pages, with 64 engravings and 8 
plates showing colors of 64 tests, and a spectra plate. Cloth, $3.00, net. 
It is difficult to see how abetter the covers of this book. — The North- 

book could be constructed. No man western Lancet. 

who devotes himself to the practice Its statements are all clear and its 

of medicine need know more about teachings are practical. — Virginia 

chemistry than is contained between Med. Monthly. 

SLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- 
MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. 



26 Lea Brothers & Co., Philadelphia and New York. 

SMITH (EDWARD). CONSUMPTION; ITS EARLY AND REME- 
DIABLE STAGES. In one 8vo. volume of 253 pp. Cloth, $2.25. 

SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- 
FANCY AND CHILDHOOD. Eighth edition, thoroughly revised 
and rewritten and much enlarged. In one large 8vo. volume of 983 
pages, with 273 engravings and 4 full-page plates. Cloth, $4.50; 
leather, $5.50. 



The most complete and satisfac- 
tory text-book with which we are 
acquainted. — American Gynecologi- 
cal and Obstetrical Journal. 



A safe guide for students and phy- 
sicians. — The Am. Jour, of Obstetrics. 

For years the leading text-book on 
children's diseases in America. — 
Chicago Medical Recorder. 

SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- 
oughly revised edition. In one octavo volume of 892 pages, with 
1005 engravings. Cloth, $4 ; leather, $5. 



dium for the modern surgeon. — Bos- 
ton Medical and Surgical Journal. 



One of the most satisfactory works 
on modern operative surgery yet 
published. The book is a eompen- 

SOLL.Y (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- 
TOLOGY. In one handsome octavo volume of 462 pages, with en- 
gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. 



A clear and lucid summary of 
what is known of climate in relation 
to its influence upon human beings. 
— The Therapeutic Gazette. 



Every practitioner of medicine 
should possess himself of a copy and 
study it, and we are sure he will 
never regret it. — St. Louis Medical 
and Surgical Journal. 

STELLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- 
ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- 
MENT. In one 12mo. volume of 163 pages, with a chart showing 
routes of previous epidemics. Cloth, $1.25. 

THERAPEUTICS AND MATERIA MEDICA. Fourth and 

revised edition. In two octavo volumes, containing 1936 pages. 
Cloth, $10; leather, $12. 

STBLIiE (ALFRED), MAISCH (JOHN M.) AND CASPARI 
(CHAS. JR.). THE NATIONAL DISPENSATORY: Containing 
the Natural History, Chemistry, Pharmacy, Actions and Uses of 
Medicines, including those recognized in the latest Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous refer- 
ences to the French Codex. Fifth edition, revised and enlarged, 
including the U. S. Pharmacopoeia, Seventh Decennial Revision. 
With Supplement containing the National Formulary. In one 
magnificent imperial octavo volume of about 2025 pages, with 
320 engravings. Cloth, $7.25; leather, $8. With ready reference 
Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. 



Lea Brothers & Co., Philadelphia and New York. 27 

STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. 

Fourth edition. In one royal 12mo. volume of 581 pages, with 293 
engravings. Cloth, $3.00, net. 

A useful and practieal guide for 
all students and practitioners. — Am. 
Journal of the Medical Sciences. 



The book is worth the price for the 
illustrations alone. — Ohio Medical 
Journal. 



STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND 
DISLOCATIONS. Third edition. In one handsome octavo vol- 
ume of 842 pages, with 336 engravings and 32 plates. Cloth, $5.00, 
net; leather, $6.00, net; half Morocco, $6.50, net. 



Preeminently the authoritative 
text-book upon the subject. The 
vast experience of the author gives 
to his conclusions an unimpeachable 



value. The work is profusely il- 
lustrated. It will be found indis- 
pensable to the student and the prac- 
titioner alike. — The Medical Age. 



STUDENT'S QUIZ SERIES. Thirteen volumes, convenient, author- 
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STUDENT'S SERIES OF MANUALS. 12mos. of from 300-540 
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Clarke and Lockwood's Dissector's Manual, $1.50. 
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STURGES (OOTAVIUS). AN INTRODUCTION TO THE STUDY 
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SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE 
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SZYMONOWICZ (L.) AND MacCALLU3I (J. BRUCE). A 
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28 Lea Brothers & Co., Philadelphia and New York. 

TAIT (L.AWSON). DISEASES OF WOMEN AND ABDOMINAL 
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TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- 
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TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New 

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engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50. 

To the student, as to the physician, be found to be thorough, authorita- 

we would say, get Taylor first, and tive and modern. — Albany Law 

then add as means and inclination Journal. 

enable you.— American Practitioner Probably the best work on the 
and News. subject written in the English Ian- 

It is the authority accepted as guage. The work has been thor- 
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speaking countries. The work will Pacific Medical Journal. 

ON POISONS IN RELATION TO MEDICINE AND MEDI- 
CAL JURISPRUDENCE. Third American from the third London 
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Cloth, $5.50 ; leather, $6.50. 

TAYLOR (ROBERT W.). GENITO-URINARY AND VENEREAL 

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handsome octavo volume of 720 pages, with 130 engravings and 27 

colored plates. Cloth, $5.00, net; leather, $6.00, net. 

By long odds the best work on | It is a veritable storehouse of our 

venereal diseases. — Louisville Medi- knowledge of the venereal diseases. 

cal Monthly. ' It is commended as a conservative, 

The clearest, most unbiased and practical, full exposition of the 

ably presented treatise as yet pub- greatest value. —Chicago Clinical 

lished on this vast subject.— The Review. 

Medical News. 

TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- 
UAL DISORDERS IN THE MALE AND FEMALE. Second 
edition. In one 8vo. volume of 434 pages, with 91 engravings and 
13 colored plates. Cloth, $3.00, net. 
The author has presented to the followed, will be of unlimited value 

profession the ablest and most scien- to both physician and patient. — 

tific work as yet published on sexual Medical News. 

disorders, and one which, if carefully 

A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. 

Including Diagnosis, Prognosis and Treatment. In eight large folio 
parts, measuring 14 x 18 inches, and comprising 213 beautiful figures 
on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 
pages of text. Complete work now ready. Price per part, sewed in 
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$27 ; half Turkey Morocco, $28. For sale by subscription only. Address 
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Lka Brothers A Co., Philadelphia and New York. C9 



TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for 
the use of Senior Students and others. In one large 12mo. volume of 
802 pages. Cloth, $3.75. 

THOMAS (T. GAILiLARD) AND MUNDE(PAUL P.). A PRAC- 
TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth 
edition. In one octavo volume of 824 pages, with 347 engravings. 
Cloth, $5 ; leather, $6. 



The best practical treatise on the 
subject in the English language. 
It will be of especial value to the 
general practitioner as well as to the 
specialist. The illustrations are very 
satisfactory. Many of them are new 
and are particularly clear and attrac 



This work, which has already gone 
through five large editions, and has 
been translated into French, Ger- 
man, Spanish and Italian, is the 
most practical and at the same time 
the most complete treatise upon the 
subject. — The Archives of Gynecol- 



tive. — Boston Med. and Sur. Jour. I ogy, Obstetrics and Pediatrics. 

THOMPSON (W. GIL.MAN). A TEXT-BOOK OF PRACTICAL 

MEDICINE. For Student's and Practitioners. In one handsome 
octavo volume of 1012 pages, with 79 engravings. Cloth, $5.00, 
net; leather, $6.00, net; half Morocco, $6.50, net. 

THOMPSON (SLR HENRY). CLINICAL LECTURES ON DIS- 
EASES OF THE. URINARY ORGANS. Second and revised edi- 
tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. 

THE PATHOLOGY AND TREATMENT OF STRICTURE 



OF THE URETHRA AND URINARY FISTULA. From the 
third English edition. In one octavo volume of 359 pages, with 47 
engravings and 3 lithographic plates. Cloth, $3.50. 

TIRARD (NESTOR). MEDICAL TREATMENT OF DISEASES 
AND SYMPTOMS. Handsome octavo volume of 627 pages. Cloth, 
$4.00, net. 



This work will rapidly come into 
favor with students and practition- 
ers. It deals comprehensively with 
therapeutical medications and pre- 
sents a great number of well-selected 
formulas of every day use. Certainly 



this is a work destined to become 
popular, and we take great pleasure 
in commending it in the highest 
terms. — Nashville Journal of Medi- 
cine and Surgery. 



TODD (ROBERT BENTL.EY). CLINICAL LECTURES ON CER- 
TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. 

TREVES (FREDERICK). OPERATIVE SURGERY. In two 
8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 

A SYSTEM OF SURGERY. In Contributions by Twenty-five 



English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, 
with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
487 engravings and 2 colored plates. Complete work, cloth, $16.00. 

TREVES (FREDERICK). SURGICAL APPLIED ANATOMY. 

New edition. In one 12mo. volume of 600 page6, with 61 engravings. 
Cloth, $2.00, net. See Student's Series of Manuals, page 27. 



30 Lea Brothers A Co., Philadelphia and New York. 



TUTTLE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES 
OF CHILDREN. In one handsome 12mo. volume of 374 pages, 
with 5 plates. Cloth, $1.50, net ; flexible red leather, $2.00, net. Lea's 
Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. 
See p. 17. 

of infancy and childhood into short 



It is a good work — the author hav- 
ing condensed most of the leading 
points in connection with diseases 



and readable chapters. — Virginia 
Medical Semi-Monthly . 



VAtTGHAN (VICTOR C.) AND NOVY (FREDERICK G.). 

CELLULAR TOXINS, or the Chemical Factors in the Causation of 
Disease. New (4th) edition. In one 12mo. volume of 480 pages. Cloth, 
$3.00, net. 



The work has been brought down 
to date, and will be found entirely 
satisfactory. — Journal of the Ameri- 
can Medical Association. 



The most exhaustive and most re- 
cent presentation of the subject. — 
American Jour, of the Med. Sciences. 



VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1902. 
Four styles : Weekly (dated for 30 patients); Monthly (undated for 
120 patients per month) ; Perpetual (undated for 30 patients each 
week); and Perpetual (undated for 60 patients each week). The 60- 
patient book consists of 256 pages of assorted blanks. The first three 
styles contain 32 pages of important data, thoroughly revised, and 
160 pages of assorted blanks. Each in oile volume, price, $1.25. 
With thumb-letter index for quick use, 25 cents extra. Special rates 
to advance-paying subscribers to The Medical News or The 
American Journal of the Medical Sciences, or both. See p. 32. 

WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
PRACTICE OF PHYSIC. A new American from the fifth and 
enlarged English edition, with additions by H. Hartshorne, M. D. 
In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 

WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the third English edition. In 
one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. 

WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- 
ING. Fifth edition. In one 12mo. volume of 640 pages, with 
509 engravings, many of which are photographic. $3.00, net. 



The part devoted to bandaging is 
perhaps the best exposition of the 
subject in the English language. It 
can be highly commended to the 
student, the practitioner and the 
specialist. — The Chicago Medical 
Recorder. 



Well written, conveniently ar- 
ranged and amply illustrated. It 
covers the field so fully as to render 
it a valuable text-book, as well as a 
work of ready reference for sur- 
geons. — North Amer. Practitioner. 



WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR 

THERAPEUTIC INDEX. Including Medical and Surgical Thera- 
peutics. In one square octavo volume of 917 pages. Cloth, $4. 



Lea Brothers & Co., Philadelphia and New York. 31 



WHIDIVN'S (ROYAXj). ORTHOPEDIC SURGERY. One octavo 
volume of «)4l2 pages, with 447 illustrations. Cloth, $5. •"><), net. 

WIIililAMS (DAWSON). THE MEDICAL DISEASES OF CHIL- 
DREN. Second edition. Specially revised for America by F. S. 
CHURCHILL, A.M., M.D. In one octavo volume of 538 pages, with 
52 illustrations, and 2 plates. Cloth, $3.50, net. 

The descriptions of symptoms are diagnoses, prognosis, complications, 
full, aud the treatment recommended and treatment. The work is up to 
will meet general approval. Under I date in every sense. — The Charlotte 
each disease are given the symptoms, Medical Journal. 

WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. 

A new and revised American from the last English edition. Illustrated 
with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ; 
leather, $5. 

WLNCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. 
Translated by James R. Chadwick, A. M., M. D. With additions 
by the Author. In one octavo volume of 484 pages. Cloth, $4. 

WOELLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated 
from the eighth German edition, by Ira Remsen, M. D. In one 
12mo. volume of 550 pages. Cloth, $3. 

WOOLSEY (GEORGE). APPLIED SURGICAL ANATOMY RE- 
GIONALLY PRESENTED. Octavo, 511 pages, with 125 original 
illustrations in black and colors. In press. 

YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. Sec- 
ond edition. In one 12mo. volume of 592 pages, with 4 engravings. 
Cloth, $2.50. See Series of Clinical Manuals, page 26. 
We doubt whether any book on I work of Dr. Yeo's. The value of 



dietetics has been of greater or more 
widespread usefulness than has this 
much-quoted and much-consulted 



the work is not to be overestimated. 
— New York Medical Journal. 



YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. 
volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. 

In studying the different chapters, surgical specialty and every page 

one is impressed with the thorough- abounds with evidences of prac- 

ness of the work. The illustrations ticality. It is the clearest and most 

are numerous — the book thoroughly modern work upon this growing de- 

practical — Medical News. partment of surgery. — The Chicago 

It is a thorough, a very compre- Clinical Review. 
hensive work upon this legitimate 

ZAPFFE (F. C). A POCKET TEXT-BOOK OF BACTERIOLOGY. 
Handsome 12mo. of about 350 pages, amply illustrated. Preparing. 



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PROGRESSIVE MEDICINE. 

A Quarterly Digest of New Methods, Discoveries, and Improvements 
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